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Full text of "The Filaria sanguinis hominis and certain new forms of parasitic disease in India, China, and warm countries"

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THE 



FiLARiA Sanguinis Hominis 



AND CERTAIN 



NEW FORMS OF PARASITIC DISEASE 



INDIA, CHINA, AND WARM COUNTRIES 



BY 

PATRICK MANSON, M.D., CM. 
Amoy, China 



LONDON 
H. K. LEWIS, 136, GOWER STREET, W.C. 



PREFACE, 



The subjects treated of in these pages are little 
understood in Europe. A systematic account of 
them cannot be found in any text-book or j)eriodical 
easily accessible to the ordinary medical reader. 
^Nevertheless, they are of great practical and theo- 
retical importance. Any one who takes the trouble 
to go over the ground is soon convinced of this. 
I therefore thought that I might do some service 
to those who desire to work at, or learn about these 
subjects, and also that I might put others in a 
favourable position to add to our limited store of 
knowledge if I brought together into one small 
volume the gist of certain papers I have published 
' — most of them in the '' China Customs Gazette," 
a practically inaccessible periodical. 

Chapter I. is a reprint of a paper contributed 
to the ''Pathological Society's Transactions " for 1881 
(vol. xxxii.). In it, as a sort of comment on a lymph- 
scrotum exhibited to the Society, I have given a 
'precis of our knowledge of the life-history of filaria 
sanguinis hominis, and of its pathological significance. 
In the succeeding five chapters, and in foot-notes. 



IV PEEFACE. 

I have given a more detailed account of the evidence 
on which I fonnd my conclusions. I have been 
careful to do this as many, who have not taken the 
trouble to work out the subject in detail for them- 
selves, have questioned my facts, and, of course, 
denied my conclusions. The life-history of this 
parasite is so complicated, and its demonstration in- 
volves so much patient labour, that one must not 
be unprepared for this : a long time may elapse 
before accumulated confirmations have brought about 
the general acceptance of the facts I have described. 
Sceptics who have the opportunity of working ought 
to work and collect evidence before they contradict 
or o:ffer anything but a very qualified opinion. 

Endemic haemoptysis and tinea imbricata are 
both new and interesting diseases. 

The short note on the parasite called after me 
by my friend Dr. Cobbold, I have introduced in the 
hope that those who have the chance of post-mortem 
examinations in Orientals may look for the animal. 
What pathological importance it may possess I cannot 
say ; probably it will turn out to be only a helmintho- 
logical curiosity. 

The parasitic diseases, apart from any special 
interest attaching to them, possess many instructive 
and suggestive analogies to the more widely-spread 
and deadly zymotic diseases. Such facts as filarial 
periodicity, the action of intermediary hosts in the 
spread of communicable but non-infectious disease, the 
embolism of the lymph-channels by the aborted ova 
of the filaria — the disease of a disease, so to speak — 



PEErACE. .V 

ought to be full of significance to the general patho- 
logist. Analogies to the ordinary zymotic diseases 
cannot fail to occur to the attentive student of the 
parasitic diseases, and I trust these pages will 
supply one or two facts which may aid in throw- 
ing light on some obscure problems in pathology. 

From the knowledge we now possess of the life- 
history of their exciting causes, it is quite possible 
to prevent, and, in time, to stamp out the ele- 
phantoid diseases and endemic haemoptysis. Un- 
doubtedly, did these diseases affect European 
countries, by this time practical sanitarians would 
have been at work. Unfortunately they affect the 
natives of countries in which we have but a very 
secondary interest, and who are themselves abso- 
lutely indifferent to sanitary matters. But one can 
understand how, by hindering the access of the 
mosquito to drinking-water, or by filtration, or 
cooking, we might prevent the elephantoid diseases, 
and how by similar means we might put an end 
to endemic haemoptysis. In the life-history of 
most of the parasites of which we possess a little 
knowledge, there is a weak point where man may 
step in and arrest development. May we not hope 
from this, that when we know more of the life of 
other and more deadly disease- germs, a weak point 
in their histories also may be found inviting the 
attack of the sanitarian ? 

My readers will not fail to be struck with the 
crudeness and incomplete character of much of my 
work. In deprecation of their criticism I would 



VI PREFACE. 

ask them to remember that I worked under many- 
disadvantages. Besides the constant interruptions 
incident to private practice, I had to contend with 
disadvantages unknown to my more fortunate co- 
labourers at home. The absence of a good library, 
of competent assistants, of friendly advice and criti- 
cism, are serious obstacles to successful work ; added 
to these, the depressing influence of a hot climate, 
and the prejudices of my native patients, had to 
be fought against. I trust, therefore, in criticising 
my work some allowance will be made for these 
circumstances. 

I take this opportunity to thank Sir Joseph Eayrer, 
F.E.S., and Dr. Spencer Cobbold, F.E.S., for many- 
acts of kindness. To them I am much indebted for 
bringing my work before the profession in England, 
and by the stamp of their approval gaining for it a 
hearing. I have also to thank Dr. Stephen Mackenzie 
for the use of the beautiful micro-photographs of 
the filaria forming the frontispiece, and for his suc- 
cessful efforts in confirming the discovery of filarial 
periodicity. 



P. M. 



Amoy, China, 

June, 1883. 



CONTENTS, 



CHAPTER I. 

PAGE 

The Filaeia Sanguhstis Hominis, and its Pathological Sig- 
nificance 1 

CHAPTER II. 
Filarial Periodicity 32 

CHAPTER III. 

FiLARiA Sanguinis Hominis : Destiny oe the Embryo Parasites 

NOT removed EROM THE BlOOD 62 

CHAPTER IV. 

The Filaria Sanguinis Hominis at Amoy, China; the Pro- 
portion OF THE Population aefected ; the Influence 
of Age, Sex, and Occupation; and the Associated 
Morbid Conditions 71 

CHAPTER V. 

The Filaria Sanguinis Hominis : Clinical Evidence of the 

Parasitic Nature of the Elephantoid Diseases . . 82 



Vlll CONTENTS. 

CHAPTER VI. 

PAGE 

Clinical Evidence foe the Theoet that the Elephantoid 
Diseases ake caused by Embolism of the Lymphatics 
BY the Oya of Eilaria Sangiiikis HoMxisris. . . . . 122 

CHAPTER VII. 

DiSTOMA RlNGEEI AND EnDEMIC HEMOPTYSIS 134 

CHAPTER VIII. 
LiGULA Mansoni 157 

CHAPTER IX. • 
Tinea Imbeicata, an Undesceibed Species of Body Ringwoem 162 



ILLUSTRATIONS. 



■— Uv^JyiVjASktr*— 



PLATE I (Frontispiece). 

Fig. 1.— Four filarise, as seen ia the blood, at an enlargement of about 
70 diameters. 

Fig. 2. — A filaria at an enlargement of about 270 diameters. The 
granular appearance of the body is a post-mortem change. 

Fig. 3. — Filaria at an enlargement of about 270 diameters, staiaed 
with anilin, showing partial retraction from external 
sheath. 

PLATE 11. 

Metamohphosis of the Filabia est the Mosgtjito. 

When the number of hours is alluded to, it is meant to express only 
the number of hours from the time the mosquito was captured to the 
time its abdomen was opened. As it would be impossible to say when 
a given mosquito fed, whether early in the evening, at midnight, or 
towards morning, a latitude of from one to nine hours must be granted 
in estimatiag the time the filaria has been subjected to the influence of 
its intermediary host. 

Fig. 1. — The filaria a short time after ingestion by the mosquito. 
Movements vigorous, but slowing down. Lash, and oral 
movements distinct. 

Fig. 2. — Movements very languid ; sheath separated by an appreciable 
interval from the body, which is transversely striated: 
from three to six hours after ingestion. 

Fig. 3. — Eight hours : Movements still more languid ; the sheath has 
disappeared ; transverse striation and oral pouting very dis- 
tinct. I note of a specimen examiaed about twenty-six 
hours after Lugestion : ' ' Many specimens dead ; one more 
active than the others showed oral movements ; the trans- 
verse striation distinct, and inside this many dark and 
shining specks seen moving as if in a fluid." 

* 



ILLUSTRATIONS. 

PLATE 11.— Continued. 
Fig. 4. — Dead and probably imdergoing degeneration or digestion. 

Fig. 5, — Thirty-six hours after capture of mosquito : Movement inter- 
mitting, but distinct and often vigorous ; faint indication 
of a double outline ; body granular ; jointed nature of 
caudal appendage very evident. 

Fig. 6. — Thirty-six hours after capture : Tail distinctly differentiated ; 
breadth of body g-o^g^g-in. Specimens very similar to this 
were found up to sixty hours, with tail rather more dis- 
tinctly differentiated, a faint double outline, and an obscure 
convoluted-like arrangement in the interior of the body. 

Fig. 7. — Thirty-nine hours : Length, g^^-in. ; breadth, ^-^^-in. No 
mouth or striation visible ; faint double outline ; hardly any 
granules in interior, except about the head, where they 
are faint and fine ; intermitting but vigorous flexion of 
the tail, and perhaps slight movement of body. 

Fig. 8. — Forty-nine hours : Specimens like this embedded in oily, white, 
digested-looking material. Still blood in mosquito's 
stomach, but the embryos in this all dead. In the speci- 
men represented the body is thick and finely granular ; 
the granules are shining, and have a faint though quite 
distinct movement. 

Fig. 9. — Fifty hours : Faint caudal movements ; no striation, granula- 
tion, or structure of any sort visible. 

Fig. 10. — Sixty-three hoiu-s : Body homogeneous ; slight indication only 
of a tail ; thicker and shorter ; one specimen shows faint 
indication of striation. To one slide water was added, and 
pretty vigorous movement followed, and the tail was again 
seen, 

PLATE III. 

Metamokphosis of the FrLA^iA IN THE MosQUiTO — Continued. 

Fig. 1 . — Seventy to ninety hours (4th day) : Many specimens like that 
represented ; tail particularly distinct, some indication of a 
mouth with lips ; some specimens are quite structureless 
in the interior, whereas in others an indistinct convoluted 
appearance can be made out ; all are quite motionless. 

Fig. 2. — 5th day : Nearly all mosquitos are dead, their ova having 
been deposited on the water. In a living mosquito embryos 
as at Fig. 1 ; in another mosquito many embryos as at 
Fig. 2 ; a distinct foiu'-lipped mouth visible ; wath a high 
power a double outline is easily made oiit, and it becomes 
apparent that the tail is merely an integumeutal appendage. 
Indications of alimentary ca,nal. 



ILLUSTRATIONS. 

PLATE 111.— Continued. 

Fig. 3. — oth clay: Body elongating-; granular or cell-like appearance 
in iaterior ; indications of an anus. 

Fig. 4. — 5th and 6th day : Body stiU longer ; posterior end swelling ; 
granular matter escaping from anus; aHmentary canal 
distinctly indicated ; tail shrinking, but still occasionally 
exhibiting movements of flexion and extension. 

Fig. 5. — From mosquito on the 6th day : Body of developing embryo 
short and stumpy ; mouth, alimentary canal, and anus 
distinct ; in two the tail has disappeared ; in one some 
slight indications of it remain ; bodies filled with large 
cells ; larger cells posteriorly. 

Fig. 6. — 5th to 6th day: Body broader and more elongated ; tail, a mere 
stump ; mouth, alimentary tube, oesophagus, valve, and 
intestine very distinct ; head and fore-part of the body 
rocked backwards and forwards in rapid swaying motion. 

Fig. 7. — 5th to 6th day: Body now the thirtieth of an inch in length, 
very transparent ; the animal in constant motion, rushing 
backwards and forwards through the water, and forcing 
obstacles of all sort aside. Drawn on a smaller scale. 

Fig. 8. — Head and tail of No, 7, the animal being restrained and 
crushed by pressiu-e on the cover glass, (a) The head is 
seen to be crowned with four strong circumoral papillas 
(the boring apparatus) ; the ruptured end of the oesophagas 
protrudes where the body has been torn across, and in 
front of this a faint line is seen emerging on the surface of 
the integiiment, and is probably the rudiment of uterus 
and vagina. (b) The alimentary canal is seen to enter 
the ruptiu'ed end of the tail. No anus visible. Caudal 
appendage completely disappeared. 

PLATE IV. 

Lymph- scrotum and elephantiasis scroti ; lymphatic glands of the groin 
and lymphatics of scrotum varicose. — Case VII. 

PLATE V. 

Elephantiasis of leg and operation flaps supervening in a case in which 
a lymph-scrotum had been excised. — Case XVIII. 

PLATE VI. 

Elephantiasis of the leg, varicose groin-glands, and lymph-scrotum 
combined. — Case XIX. 



ILLUSTRATIONS. 



PLATE VII. 

Elephantiasis of the leg ; lymphous discharge from calf of leg : varicose 
groin-glands ; chyluria. — Case XXI. 

PLATE VIII. 

Ova of Distoma Rwgeei, and Development of the Embryo. 

Figs. 1, 2, 3. — Ova newly expectorated. 

Fias. 4, 5, 6, 7, 8, 9. 

PLATE IX. 

Ova of Distoma Ringeei, and Development of the Embeyo — 
Continued. 

Figs. 1 and 2. — Ova after washing and immersion in fresh water for 
various periods ; segmentation and gradual development 
of embryo. 

Fig. 3. — Embryo in ovum soon after appearance of cilia ; movement 
commencing. 

Fig. 4. — The same after extrusion from ovum by pressure ; the beak 
protruding ; large globules appearing in the body ; death 
approaching. 

Fig. 5. — The shell from which an embryo has escaped ; the operculum 
thrown back. 

Figs. 6, 7, 8, 9. — The free embryo, assuming various shapes accord- 
ing to the character of movement it is indulging in. 

PLATE X. 

The Fungus of Tinea Imbeicata. 

Figs. 1 to 7. — Drawn from specimens treated with liquor potassse and 
stained with vesuvin brown. 

Fig. 8. — Stained with safEranin. 



WOODCUTS. 

Page 25. — "Woodcut showing the stretching of its chorional envelope 
by the embryo of the Jilaria corvi torquati. 

Page 128. — Fragment of female ^^arj'a sanguinis Ao?«m«s from abscess 
in thigh. 



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THE 

riLARIA SANGUINIS HOMINIS. 

CHAPTER I. 

THE riLARIA SANGUINIS HOMINIS, AND ITS 
PATHOLOGICAL SIGNIFICANCE.* 

The preparation exhibited to the Society on May 
17th, by Dr. Thin, as an example of the disease I 
have called lymph-scrotum, j" is unique. For although 
lymph-scrotum is common enough in certain coun- 
tries, and as a morbid preparation has occasionally 
been exhibited in Europe, and the parent of the 
hsematozoon, named by Lewis filaria sanguinis 
hominisy has been found by at least four observers, 
yet I believe this is the first instance in which 
the parasite has been found in its proper habitat, 
a lymphatic vessel, and has been seen in situ. % 

* This chapter is a reprint of a paper contributed to the 
** Pathological Society's Transactions" for 1881, vol. xxxii. 

t This disease has received various names, as varix 
lymphaticus, nsevoid elephantiasis, etc. Lymph-scrotum is 
shorter and more expressive. 

J For a full report of this case, see p. 123. 

B 



2 THE FILAEIA SANGUINIS HOMINIS. 

The man from whom this lymph-scrotum was 
removed last October, had suffered from symptoms 
of lymphatic obstruction for about five years. At 
intervals lymph was discharged from vesicles on the 
surface of the scrotum, and for the last three years 
the discharge had been almost constant. The usual 
and characteristic vesicles covered the lower part 
of the scrotum, the tissues of which were thickened, 
but not indurated or greatly enlarged ; to the touch 
they felt soft and spongy. The groin glands on 
both sides were enlarged, and felt indurated, or 
rather as if an indurated nucleus was surrounded 
by a spongy and varicose cortex. The clear and 
straw-coloured coagulable lymph contained embryo 
filarise ; but, though frequently searched, blood from 
the finger contained no parasites. The man's 
spleen was considerably enlarged, and he was in- 
tensely anaemic. As there seemed no prospect of the 
lymphorrhagia ceasing, to save his life I was com- 
pelled to remove the scrotum. Before operating I 
ventured to prognosticate that the parent filaria would 
be found in the part removed. That 1 was justified 
in making this prognostication was proved by the 
parasite appearing on the cut surfaces of the scrotum 
in active movement. It turned out to be a female. 
Half of the animal lay in a dilated lymphatic, and 
is still there ; for, on attempting to withdraw it, the 
body snapped across. Probably the male is there also. 

In order to make clear the reasons for the pro- 
gnostication I made, it is -necessary to examine the 
entire subject of filaria sanguinis hominis^ and its 
connection with certain diseases — a subject as yet 
little understood, but one destined, both from its 



PATHOLOGICAL SIGNIPICANCE. 6 

scientific interest and vast practical importance, to 
occupy no insignificant place in pathology. 

Its enormous practical importance will be com- 
prehended when I state that wherever elephantiasis * 
is endemic this parasite is to be found ; that elejDhan- 
tiasis is endemic over half the globe, at least over 
that part of the globe where the major part of 
mankind resides ; that this parasite produces a group 
of diseases, very common in these countries, which, 
though not commonly fatal, do sometimes kill, and 
always give rise to much pain, deformity, and incon- 
venience ; that it is in our power completely to 
prevent the access of the animal to the tissues of 
man, and thereby prevent these diseases ; and that 
this desirable result can be attained by the simplest 
of means. These seem sweeping statements, but the 
sequel, I am convinced, will fully bear me out in 
making them. 

For a complete account of the gradual progress 
of our knowledge of this parasite I would refer 
the reader to Cobbold's recently- published work on 
" Parasites. "t There the history of the subject is 
given, along with an exhaustive bibliography, down 
to the date of the publication of his work. I will 
confine myself to stating only so much of the history 
as is necessary to understanding the subject, and will 
avoid, as much as possible, everything that appears to 
me unimportant or doubtful. 

* When the term elephantiasis is used, elephantiasis 
arabnm is meant ; never elephantiasis grsecorum or leprosy. 

t " Parasites : a Treatise on the Entozoa of Man and 
Animals." By T. Spencer Cobbold, M.D., F.R.S. London, 
1879. 

b2 



4 ' THE FILARIA SANGUINIS HOMINIS. 

The animal I saw wriggling on the cut surface of 
the scrotum shown to the society, and half of 
whose body is still lying in the lymphatic vessel it 
occupied during life, is the parent of an embryo 
nematode, first found in chylous urine by Wucherer 
in 1866, and in the blood by Lewis in 1872, and 
named by the latter observer filaria sanguinis hominis. 
The embryo was discovered several years before the 
mature animal, for it was not till 1876 that Bancroft 
in Australia, and a few months later, in 1877, Lewis 
in India, found the parent worm. Since then the 
mature animal has been found by Araujo and dos 
Santos in Brazil, and by myself in China, and has 
been named by Cobbold Filaria Bancrojti. Only a 
small part of the male worm has hitherto been foimd, 
and as in this case it was intimately associated with 
the female, it is extremely probable that the sexes 
live together. Like the males of most filarise it was 
considerably smaller than the female. The latter is 
a long, slender, hair-like animal, quite three inches 
in length, but only y^-in. in breadth, of an opaline 
appearance, looking as it lies in the tissues like a 
delicate thread of catgut animated and wriggling. A 
narrow alimentary canal runs from the simple club- 
like head to within a short distance of the tail, the 
remainder of the body being almost entirely occupied 
by reproductive organs. The vagina opens about 
-2-5-in. from the head ; it is very short, and bifurcates 
into two uterine horns, which, stuffed with embryos at 
all stages of development, run backwards nearly to the 
tail. Under the microscope fully-formed embryos, just 
as we see them in the blood, can be seen escaping 
from the vagina. The animal is therefore vivij)arous. 



PATHOLOGICAL SIGNIFICANCE. 5 

For further details on the structure of the parent 
worm Lewis's and Cobbold's writings should be 
consulted.* Here I may not occupy space with hel- 
minthological detail unnecessary for the full under- 
standing of my argument ; but there is one point it 
would be well to settle before proceeding with the 
history of the parasite, and that is, the exact position 
occupied by the mature animal in the human body — 
what tissue or vessel. 

The preparation shown to the Society is almost 
sufficient to settle this. In it, when fresh, and im- 
mediately after its removal from the body, the animal 
was seen protruding from the cut end of a lymphatic 
vessel from which it had partly crept out ; the 
other end of the dilated vessel was seen in the face 
of the wound, and from it, the groin-glands being 
pressed with the hand, lymph was seen to regurgitate. 
Even prior to this the lymphatics were credited with 
being the proper habitat of the animal, for in many 
cases of lymph-scrotimi, ehyluria, and varicose groin- 
glands, its young have been found in the lymph. f 
It might have been objected to this, as a conclusive 
argument, that possibly those embryos found their 
way into the lymphatics by escaping from the capil- 
laries. This is extremely unlikely ; yet, admitting 
its possibility in the case of the free embryo, such a 
feat would be impossible to the ovum both on account 

* " The Microscopic Organisms found in the Blood of Man 
and Animals, and their Relation to Disease." By Timothy 
Eichard Lewis, M.B. Reprinted from the " Fourteenth 
Annual Report of the Sanitary Commissioner with the 
Grovemment of India," 1877. 

t See many of the cases related in chapters iv. and v. 



6 THE FILARIA SANGUINIS HOMINIS. 

of its diameter and its being a perfectly passive body. 
Ova, however, have been found in the lymph,* and 
the ovum being too large to pass from the outside 
to the inside of a lymphatic, and having no power 
to work its way, the parent that laid it must have 
communicated directly with the lymphatics. Again, 
in not a few instances filaria embryos have been 
found in the lymph discharges of individuals from 
whose blood not a single specimen could be obtained ;•}* 
they could not, therefore, have come from the blood- 
vessels. It may be taken as settled that the parent 
worm lives in the lymphatics. 

Thus, then, the parent filaria lying in a lymphatic 
vessel emits her young into the lymph-stream ; along 
this they are carried to the lymphatic glands. As 
they are only about 3^5^-in. in diameter, no broader 
than many of the lymph-corpuscles that accompany 
them, they have no difficulty in entering and travers- 
ing the minute vessels into which the afferent 
lymphatic divides. Eor the same reason, and by 
virtue of its vigorous movements, it passes the 
parenchyma of the gland, and emerging into the 
efferent vessels is borne along the current till, 
having traversed gland after gland, it finds itself 
in the thoracic duct, and finally in the blood itself. 

As found there, and also in the lymph, this 
nematode embryo when examined by a high micro- 
scopic power is seen to be a long, slender, snake- 
like, gracefully-shaped animal, possessed of an 
activity so great that until paralysed by approaching 

* See Case XXIV. p. 130 ; and Case XXY. p. 131. 
t See Case XIY. p. 103 ; Case XX. p. 115 ; Case XXI. 
p. 116 ; Case XXII. p. 123. 



PATHOLOGICAL SIGNIFICANCE. 7 

death or inspissation of the medium it lies in 
measurements and observations of structure can 
hardly be made. It measures about g^-in. X asVo'i^*) 
is perfectly transparent, and apparently structui-eless. 
The anterior part of the body tapers slightly, and 
at its very extremity a pouting movement, as if of 
breathing, is to be detected. Posteriorly the body 
gradually tapers down to a fine point, the extreme 
end of which in most specimens has the look of 
being articulated, for this part does not always har- 
monize with the general curve of the body, but seems 
bent at an angle. In some individuals a brown 
aggregation of granular matter can be detected about 
the centre of the body half way between head and 
tail. An extremely delicate sac encloses the animal, 
fitting it accurately ; but as this sac is about one- 
third longer than the body it is unoccupied and 
collapsed into the semblance of a lash at the head, or 
tail, or both, according to the position or direction of 
movement of its contents. If the animal is rushing 
forward, the anterior part of the sac is occupied and , 
a long lash of collapsed sac dangles from the tail ; 
if the animal is retreating tail first, then this part 
of the sac is occupied and the superfluous integument 
trails after the head. (Plate I.) 

If a man in whose blood this parasite has been 
found is kept constantly under observation for a 
number of days, and freshly-drawn specimens of his 
blood examined at short intervals, it will soon be 
evident that the parasite is not equally abundant at 
all times ; in fact, that often it is entirely absent. 
Sometimes slide after slide will be examined without 
a single specimen being discovered, notwithstanding 



8 THE FILAEIA SANGUINIS HOMINIS. 

that a few hours before the parasite could be found 
by the hundred in every drop of blood. If a register 
of these observations is kept it will presently be appa- 
rent that there is a diurnal periodicity in this presence 
and absence of embryos in the general circulation. 
It will be found that during the day, unless under 
peculiar circumstances, they are entirely absent ; that 
about six or seven o'clock in the evening, with 
"military-like punctuality," as Cobbold expresses 
it, they march to their night quarters ; gradually, as 
night advances their numbers increase ; by twelve 
o'clock as many as 100, or even more, may be 
counted in every drop of blood. About this time 
their numbers reach their maximum, and then, as 
morning approaches, they become fewer and fewer ; 
by eight or nine a.m. they entirely disappear. From 
nine a.m. to six p.m. very rarely is it possible to 
procure a single specimen. The only thing that 
interrupts the regularity of this periodicity is an 
attack of fever. If this does not occur it is main- 
tained day after day. I have watched it preserve 
its rhythm for a month on end, and there is no 
reason for supposing that, but for the exception 
mentioned, it is ever interrupted.* This is a most 
remarkable phenomenon, and one as yet unaccounted 
for. But though we may not be able to explain 
it we understand its object, for night is the time 
when at the surface of the body the embryo has an 
opportunity of advancing in its development. f 

* This was written before Dr. Stephen Mackenzie showed 
that periodicity was affected by altering the hours for sleeping. 

t For a full account of filarial periodicity the reader is 
referred to chap, ii., and to Dr. Stephen Mackenzie's paper on 



PATHOLOGICAL SIGNIFICANCE. 9 

There appears to be no reason for supposing tliat 
after the embryo leaves the uterus of its parent, and 
as long as it remains in the body of the original host, 
there is any advance in development. As seen in 
the blood all look much alike ; and, indeed, it is 
evident that any degree of growth would be in- 
compatible with the life of the human host. Such a 
swarm of animalcules did they but each attain a 
hundredth part of the size of their parents would 
soon make life impossible. For this reason, as well 
as for the reason that the species to be continued 
must pass into other men, the embryo must leave the 
original host. But how ? Only on rare occasions 
have they been found in the excretions, and then only 
in those of a morbid character. 

Nature is not likely to trust to the accident of 
a disease for the continuation of a species. Her 
operations are always orderly and reveal a plan. She 
may be careless of the single life, but she is very 
careful of the species. Seeing, then, that there is no 
provision made in the structure of the embryo for its 
spontaneously escaping from the body, and that this 
escape must be e£tected, it follows that some outside 
influence must bring this about. 

In the somewhat analogous parasite, trichina 
spiralis^ such an opportunity is afforded by the 
animal that devours the flesh of the original host. 

" A Case of Filarial Hsemato-chyluria," in the " Transactions 
of the Pathological Society of London," 1882, vol. xxxiii. ; 
also to a very interesting paper on " Filaria Disease in South 
Formosa," by Dr. W. Wykeham Myers, in the " China Cus- 
toms Medical Reports," for the half-year ended March 31st, 
1881; 21st issue. 



10 THE FILARIA SANGUINIS HOMINIS. 

But in few countries is human flesh, consumed in 
so wholesale a fashion as would warrant us sup- 
posing the filaria sanguinis liominis was similarly 
treated. 

As the embryo parasite lives in the blood it is 
likely that the first step in its development and 
towards freedom will be given it by something that 
abstracts the blood. Thus, then, the privilege will 
be confined to a very limited number of animals — 
the blood-suckers. This includes the fleas, lice, bugs, 
leeches, mosquitos, and sand - flies. But as the 
parasite is confined to a limited area of the earth's 
surface it is more than likely that this friend of the 
filaria has a corresponding and limited distribution. 
Fleas, lice, bugs, leeches, as they are found pretty 
well all the world over, must therefore be excluded. 

Eeasoning in this way I concluded in the summer 
of 1877 * that either the mosquito or the sand-fly 
liberated the parasite. Had I been aware then of the 
nocturnal habits of the worm I would have excluded 
the sand-fly likewise. In this way, then, reasoning 
from its faculty of piercing the blood-vessels, its noc- 
turnal habits, and its geographical distribution, the 
mosquito appears of all animals the most suited to 
assist the parasite. And as there are many species of 
mosquitos everywhere in the tropics, and in many 
other parts of the world, but filaria disease is limited, 
it follows that every species of mosquito will not 
answer ; it must be a species similarly limited. I 
know of several tropical sjDccies that are impotent to 
assist the parasite ; but there is at least one species 

* " China Customs Medical Eeports," No. 14, 1878 ; "Lin- 
nsean Society's Journal of Zoology," vol. xiv. p. 304. 



PATHOLOGICAL SIGNIFICANCE. 11 

possessing all the necessary qualifications, and which 
others, as well as myself, have over and over again 
proved to be an efficient intermediary host for filaria 
sanguinis hominis.* The female of this particular 
species of culex (it is with her alone we have to 
deal, the male, owing to the construction of his oral 
appendages, being incapable of piercing the skin) 
is a small, dark-brown insect, about i^-in. in length. 
She may be recognized by her size, her colour, and 
the entire absence of pronounced markings on her 
abdomen, thorax, or legs. Her head is small and 
dark, and carries a proboscis about two-thirds the 
length of her body, dark, too, like the head, strong, 
and slightly bulbous at the free extremity. About 
sunset the sexes leave their retreat, and for an hour 
or two wheel about in the air, generally, when in a 
house, near the ceiling. About eight o'clock they 
descend in search of food, and the female greedily 
avails herself of the blood of the first animal in 
which she can fix her proboscis, be it man or beast. 
About two minutes suffice, if she is not disturbed, to 
fill the stomach. She then retires to some shady 
place, if possible in the vicinity of water, and 
during four or five days is occupied in digesting 
her single meal and maturing her ova. When this is 

* Lewis : op. cit. ; Araujo (see Cobbold's " Parasites," p. 
198) ; Bancroft (" Diseases of Plants and Animals/' etc. ; a 
pamphlet published in Brisbane, Australia). Dr. Sonsino, 
of Cairo, Egypt, wrote me lately saying that he also had 
recently observed the metamorphosis of the filaria in the 
mosquito. Specimens of filaria-impregnated mosquitos I 
sent home some years ago to Dr. Cobbold, have on several 
occasions been exhibited at different medical and scientific 
societies in London. 



12 THE FILAEIA SANGUIXIS HOMINIS. 

completed she betakes herself to the water, and on 
the surface of this deposits two little boat-shaped 
masses of eggs. After effecting this she dies. 

If, then, a female of this particular species of 
mosquito pierces the skin of a filaria-infested subject, 
the proboscis, buried in the blood-stream, is speedily 
beset by the embryos. These as they are carried 
along by the current become entangled by their 
lashes,* and are then transferred in great abundance, 

* Many of the hoematozoa of the lower animals which I have 
studied are, unlike that of man, quite naked and unprovided 
with a sheath or lash. This arrangement probably has 
reference to the well-being of the parasite. The purpose of 
the lash in Jilaria sanguinis hominis ia, doxxhtless,, to assist in its 
transferrence to the stomach of the mosquito in the way I 
describe. Occasionally I have had an opportunity of making 
an experiment which goes a long way to prove this. A not 
infrequent accompaniment of filaria disease, perhaps the only 
symptom of it, is that sort of dxopsy of the tunica vaginalis 
which liasbeen called "galactocele"; properly it should be called 
" lymphocele." In this affection the congested lymphatics 
reheve themselves by rupture into the tunica vaginalis, and 
we have accordingly a collection of filaria-bearing lymph in 
this sac. Such a condition may be suspected when the glands 
of the groin are much enlarged and varicose, and the swell- 
ing of the testicle does not transmit light as in ordinary 
hydrocele. If now we tap such a " lymphocele," instead of 
the clear fluid of a hydrocele we get milky lymph such as 
escapes from ordinary lyjuph-scrotum, and in the sediment of 
this lymph filaria embryos are to be found in great abundance. 
As a rule, the lymph after withdrawal coagulates very 
rapidly, but in a certain proportion of cases coagulation does 
not occur. I do not know the reason for this absence of the 
coagulating property. I have met with such cases more than 
once. If a sample of this non-coagulating filariated Ijonph 
is procured, and into it is dropped a few fibres of cotton wool, 



PATHOLOGICAL SIGNIFICANCE. 13 

along with the blood, to the stomach of the insect. 
Here for a time they continue their movements ; 
but gradually, as the blood coagulates and becomes 
digested, motion is restricted, and finally, but for an 
intermitting jerk of the tail, entirely ceases. Some 
are digested or expelled in the faeces. A favoured 
few, however, survive, and enter on a very interest- 
ing metamorphosis. First, the hitherto smooth and 
perfectly structureless body becomes marked by 
delicate and closely-set transverse striae, as if from 
general longitudinal shrinking ; and the bag in which it 
has hitherto been tightly enveloped appears separated 
from it by an appreciable interval, and possibly finally 
disappears. Then the striae lose their distinctness, 
and the body of the animal seems as if it became 
broader, shorter, and filled with a fluid containing 
granular matter and exhibiting to-and-fro move- 
ments. The extreme tip of the tail, probably that 
portion of it described as if articulated to the rest 

it will be found that after a few minutes the cotton will sink 
to the bottom of the vessel containing the lymph. It should 
be allowed to remain there for some time, and then fished out 
with a needle and transferred to the stage of the microscope. 
If the experiment has been successful, it will be found that 
hundreds and thousands of filariae now beset the fibres of the 
cotton wound about it in every possible fashion, in groups, in 
lines, and singly, most of them being attached by their head 
or tail lashes which are wound firmly round the fibres. 
Where a kink or knot occurs, or where two or three fibres 
cross or interlace, there is sure to be a thick cluster of filarise ; 
reminding one by its appearance and the wriggling, snake- 
like movements of the parasites, of the head of the Gorgon. 
Doubtless the little worms become attached to the proboscis 
of the mosquito as they do to the cotton fibres in the experi- 
ment. 



14 THE FILARIA SANGUINIS HOMINIS. 

of the body, does not partake in the general broad- 
ening, but looks like an appendage stuck on to the 
sausage-shaped mass ; at short intervals it exhibits 
sudden and vigorous movements of flexion and 
extension. By-and-by minute cell-like bodies appear 
and arrange themselves along a line now beginning 
to be visible in the centre of the cylinder, and 
opening near, but a little in advance of the tail at 
one end, and at the semblance of a mouth at the 
other. At this stage the animal is perfectly passive, 
and its caudal appendage shortens and disappears. 
Growth now commences, and with growth a swaying 
movement of the anterior part of the body. As 
growth progresses movement increases, and finally, 
when the little animal has attained a length of about 
g^j-in., it exhibits prodigious activity, rushing for- 
wards and backwards indifferently, and thrusting 
every obstacle aside. If by pressure we restrain its 
movements, or fracture its delicate body, its head 
is seen to be crowned with three or four nipple-like 
papillae ; an alimentary canal is visible running from 
mouth to anus, and rudiments of generative organs 
can likewise be traced.* (Plates II and III.) 

* It may be useful to those who wish to repeat and test my 
observations to know the plan I found most successful in pro- 
curing filaria-bearing mosquitos, and how their bodies were 
afterwards treated for microscopic examination. One must be 
careful to procure the proper species of mosquito, and be 
assured that it has fed on filariated human blood. If any 
mosquito is caught at random there is no assurance that the 
jBlarise contained in its abdomen came from man ; quite as 
likely they may come from dog or bird. In such a case one 
cannot tell whether the parasite will be digested or will 
advance in development. The canine hoematozoon is digested 



PATHOLOGICAL SIGNIFICANCE. 15 

By the time this metamorphosis, occupying from 
four to six days, is completed, the life of the 

by the mosquito. Therefore it is all-important to work with 
the proper species of mosquito fed on human blood. 

I persuaded a Chinaman, in whose blood I had already 
ascertained that filaria3 abounded, to sleep in what is known as 
a mosquito house in a room where mosquitos were plentiful. 
After he had gone to bed a hght was placed beside him, and 
the door of the mosquito-house was kept open for half an 
hour. In this way many mosquitos entered the " house " ; 
the light was then put out, and the door closed. Next 
morning the walls were covered with an abundant supply 
of insects with abdomens thoroughly distended. They were 
then caught below a wine-glass, paralysed by means of a whiff 
of tobacco smoke, and transferred to small phials having a 
muslin cover providing for ventilation. As soon as the insects 
had recovered from the tobacco, and could adhere with their 
feet to the sides of the bottle, a few drops of water were intro- 
duced by means of a pipette. The effect of the tobacco 
smoke, if it has not been apphed too long, is very evanescent, 
and seems to have no prejudicial influence on the future of the 
mosquito. From the phials they may be removed from time 
to time as required, by again paralysing with tobacco, and 
seizing them by the thorax with a fine forceps. The abdomen 
is then torn off, placed on a glass slide, and a small cylinder 
— such as a thin penholder — rolled over it from the anus to 
the severed thoracic attachment. In this way the contents 
are safely and efficiently expressed, and observation is not 
interfered with by the almost opaque integument. If the 
contents are white and dry, a little water should be added 
and carefully mixed with the mass, so as to allow of the easy 
separation of the two large ovisacs. These can be removed 
in this way with the needle and transferred, if desired, to 
another shde for separate examination. A thin covering 
glass should be placed over the residue, which will be found 
to contain the filarise either within the walls of the stomach , 
or, if these have been ruptured by too rough manipulation, 
floating in the suiTounding water. The blood m the stomach 



IG THE FILARIA SANGUINIS HOMINIS. 

friendly mosquito is concluded ; her stomach, is empty 
but for these formidable-looking guests ; her ova have 
been deposited on the surface of the water ; her life- 
cycle is finished, and she dies, probably falling into 
the water on which her eggs were laid. What now 
becomes of her guest ? As yet we cannot tell for 
certain. Up to this point the history of the embryo 
from the time it left its parent in the lymphatic 
vessel has been followed step by step, and there 
cannot be the slightest doubt about any part of it. 
But now an hiatus in our knowledge of its life-cycle 
occurs ; and until some animal, other than man, 
capable of becoming the host of this parasite is 
discovered on which we may experiment, or some 
enthusiast willing to lend himself for the purpose 
appears, this hiatus is not likely to be filled in except 
by conjecture — conjecture founded, however, on, and 
borne out by analogy. 

By the time the mosquito dies the parasite has so 

of a mosquito that has_Jed_^n_a_filam,-mf^^ man usiially 
contains a mucnlarger proportion of filarise than does^ an 
equal quantity of blood obtained from ihe same man in the 
usual way by pricking his finger. Of course the mosquito 
feeding at night imbibes the blood at a time when it con- 
tains the largest number of parasites ; but _ apart fro m this I 
beheve the .insect, or its proboscis, has a selecting faculty 
piFobably operating in the way I have indicated in the foot- 
note at p. 12, Of the large number of filarise ingested by 
far" "the greater part die and are digested, or are expelled 
in the faeces undeveloped. At the end of the tMrd, fourth, 
or fifth day, when the stomach is quite empty as far as 
food is concerned, and an embryo could not easily be over- 
looked, only from two to six are found in the same or 
slightly different stages of the metamorphosis I have 
described. 



PATHOLOGICAL SIGNIFICANCE. 17 

far advanced in development that there seems nothing 
wanting to fit it for indejDendent life and a journey 
through the tissues of a human host. It possesses 
an alimentary canal; its head is armed with a 
boring apparatus, and it has sufficient strength and 
activity to wield this efficiently. It is also in the 
medium most likely to afford it an opportunity of 
gaining access to its final host. What more probable 
than that boring its way through the dead and sodden 
body of the insect, if it has not already escaped with 
the ova, it finds itself in the water, where it will 
remain for a longer or shorter time, perhaps to be 
captured by some animal in search of food, or, haply, 
to be swallowed by man himself ? Once in the human 
stomach it soon bores its way into the thoracic duct, 
or some lymphatic vessel ; and working up stream, in 
obedience to strange instinct, pierces the lymphatic 
glands and finally arrives at its permanent abode in 
some distant lymphatic vessel.* Here it is followed 

* Helminthology supplies us with many illustrations of 
this faculty of travelling towards, and selection of, a suitable 
habitat possessed by these lowly-organized animals. The 
same instinct guides the trichina to the muscles, the liver- 
fluke to the gall-ducts, the giant strongyle to the pelvis of the 
kidney, the hilharzia hcematohia to the veins of the bladder, 
the filaria immitls to the right ventricle of the dog, the filaria 
sanguinoknta to his oesophagus, the filaria corvi torquati to the 
pulmonary artery of the crow, the filaria piece mediae to the 
semilunar valves of the magpie ; and a similar instinct brings 
the sexes together in these dark corners. 

I would strongly recommend any one desirous of working 
at Va.e filaria sanguinis of man to make a study of some of the 
corresponding parasites of the lower animals. By doing so 
he will not only acquire skill in finding the embryo parasites 
in the blood, but will obtain a grasp of the subject which will 

C 



18 THE FILARIA SANGriNIS HOMINIS. 

by one of tlie opposite sex obedient to sexual instinct. 
The couple grow, and for years live together and 
breed, the progeny passing along the vessels through 
the glands and into the blood, there to await their 

not only interest, but be of great service. The filaria immitis 
of the dog is so common in China and Japan, that workers in 
these countries can always find plenty of material for study ; 
the examination of a drop of blood obtained by slightly 
incising or pricking the inside of the ear is an easy method of 
ascertaining if the animal is filariated. Many birds have 
hsematozoa, and in some the parent worms have been found. 
The common ringed crow of China is usually full of them, 
and the parent worms can readily be found in the pulmonary 
artery (p. 24). The magpie of that country is also infested 
with filarise, the parents residing coiled up in the pockets of 
the semilunar valves. The parent worms of the hsematozoa of 
the crow and magpie are small and beautifully transparent, 
and are excellently adapted for showing, under a low power 
of the microscope, the structm^es of the filarise. For examina- 
tion they shoidd be mounted in a saline solution — urine does 
very well ; if placed in water they swell up and burst, or if in 
spirit or glycerine they shrivel. The fluid they are mounted 
in, either for immediate examination, or for permanent speci- 
mens, ought to possess a specific gravity approaching that of 
blood. 

For some account of the filaria immitis of the dog I would 
refer the reader to Cobbold's works, or any modern treatise on 
helminthology ; and also to a " Report on Hsematozoa," by the 
author, published in the " China Customs Medical Reports " 
for the half-year ended March 31st, 1877, No. 13. Short 
accounts of the filaria piece media', of the filaria corvi torqiiati, 
and of some other hsematozoa may be found in the " Journal 
of the Uuekett Microscopical Club," vol. vi. 1880. Lewis 
gives an excellent description of the embryo of a hsematozoon 
very common in dogs in Calcutta (the mature form of which 
has not jei been found, however), in the " Sixth Report of the 
Sanitary Commissioner for the Grovernment of India," for 1869. 



PATHOLOGICAL 8IGXIFIGANCE. 19 

chance of a friendly mosquito to help them, as it 
had their parents, towards maturity. 

This, then, there can be little doubt, is an exact 
account of the life-cycle of filaria sanguinis hominis ; 
and there is nothing in it, or in its relations to the 
human host, incompatible with the perfect health of 
the latter. The amount of injary done to the 
lymphatics by the minute immature parasite in its 
travels towards its permanent abode is so trifling 
that no serious disease can possibly result from it. 
The mature animal itself lies extended in a vessel, 
and is perfectly adapted by its size and shape for 
the situation it occupies ; it creates no irritation, and 
the small amount of obstruction it may give rise to 
is readily compensated for by a rich anastomosis^ 
The embryos move along with the lymph, anc 
being no broader than the corpuscles readily pass the^ 
glands, and enter the general circulation. Here they 
give rise to no trouble, but circulate as easily as the 
blood-corpuscles.* In fact, the parasite seems in 
every respect well calculated to live in perfect har- 
mony with its host, and not at all likely to be the 
cause of serious injury or disease. Nevertheless, that 
it does become at times a cause of disease and 

* Half of the dogs in China, all the magpies, a very 
large proportion of the crows, and many other birds and 
beasts harbour similar hsematozoa, sometimes in prodigious 
numbers, often hundreds in every drop of blood, and yet 
their hosts seem perfectly healthy and in no way incon- 
venienced. The more I learn of these parasites the more I 
am convinced that when in health, and undisturbed, they are 
perfectly innocuous. Were it otherwise there would soon 
be an end to the hosts, and consequently to the parasite 
itself — both would be exterminated. 

c 2 



20 THE FILARIA SANGUINIS HOMINIS. 

danger is certain. What these diseases are, and 
how the parasite brings them about, will appear in 
the sequel. 

If in a country in which the filaria is endemic (as, 
for example, South China) the blood, say of 1,000 
natives selected indiscriminately, is examined some 
time between sunset and sunrise, in about 100 the 
filaria sanguinis hominis will be discovered. If the 
history of these filaria-infested individuals is inquired 
into it will be found that a considerable proportion 
of them enjoy good health; others suffer from 
frequent attacks of fever, characterized by well- 
marked stages of rigor, pyrexia, and diaphoresis, 
resembling in this respect ordinary intermittent fever, 
but differing from it in the irregularity and length 
of the interval — often weeks or months between 
the attacks — and also in the greater length of the 
paroxysms ; some, in addition to this history of fever, 
give a story of lymphangeitis, and may exhibit vari- 
cose groin-glands, which, they say, inflame during 
the attacks ; others have lymph-scrotum ; some have 
elephantiasis of the scrotum, or leg, or both ; others 
lymph-scrotum combined with elephantiasis of scrotum, 
or leg ; one or two may have chyluria ; and possibly 
there may be a case in which two or more of these 
affections are combined. If the 900 in whose blood 
no filarise were found are examined there very pro- 
bably will not be one, or, at all events, very many 
examples of lymph- scrotum, varicose groin-glands, 
or chyluria. There is strong presumption, therefore, 
that these diseases and the filaria are somehow 
connected. 

If we now examine the lymph that has escaped from 



PATHOLOGICAL SIGNIFICANCE. 21 

a lymph-scrotum, or that has been aspirated from 
a varicose groin-gland, or that escapes in the urine 
in chyluria,* in the great majority of cases we shall 
find in it embryo filarise. There is a strong pre- 
sumption, therefore, that the connection between the 
parasite and the disease is an intimate one. If 

* The frequent occurrence of red coagula in the urine in 
cases of chyluria appears to have had a misleading effect on 
the minds of some observers. Such cases have been called 
hsematuria, or hsemato-chyluria. But the presence of the red 
and blood-like tint admits of a much simpler explanation 
than it could receive did it depend really on blood. It is 
unlikely that the embolism of lymphatics which produces the 
chyluria should be associated with a disease or lesion of the 
blood-vessels causing hsematuria — two different diseases of the 
urinary organs occurring simultaneously in the same indivi- 
dual and not necessarily depending one on the other. It is well 
known that lymph as it travels along the lymphatics gradually 
advances in development, assuming in the thoracic duct many 
of the characters of blood, with corpuscles red and disc-shaped 
exactly like those of blood. If in any way the lymph is ob- 
structed in its progress towards the blood, there is no reason 
for supposing that it should not continue the development it 
is known to start on, in normal circumstances, in the lymph- 
atics. Therefore, it happens that the lymph we find in the 
urine in chyluria cases has often the red tinge and appearance 
of blood. It has lain a long time in the lymphatics and 
advanced somewhat in development. The same remarks 
apply to the red or dark salmon-coloured lymph that some- 
times escapes from a lymph-scrotum. We often find that 
the lymph that escapes first on pricking a lymph-scrotum is 
milk-like, but after it has run for some time that which 
escapes is red and blood-like; in other words, the more 
recently formed lymph is colourless, the lymph that has been 
formed for some time and which regurgitates from a higher 
part of the lymphatics has advanced in development, and is 
full of red, disc-shaped corpuscles. 



22 THE FILARIA SANGUINIS HOMINIS, 

we examine the lymph from one of the cases of 
lymph-scrotnm in which the disease is not associated 
with filaria in the blood, most probably we shall find 
the embryo there ; and if we amputate such a scrotum 
we have a good chance of finding in it the parent 
parasite. "We may infer from this that the relation 
of parasite and disease is one of cause and effect ; 
and, as it would be absurd to suppose the disease the 
cause of the parasite, we are driven to the conclusion 
that, in some way, the parasite has brought about 
the disease, and, inferentially, is also the cause of 
varicose groin-glands and chyluria. 

If we follow U13 for several years the histories of 
the cases of lymph-scrotum we shall find that after 
a time the periodic discharges may cease, and the 
scrotum gradually assume the characteristic appear- 
ance of ordinary elephantiasis. Sometimes we may 
meet a scrotum in the transition stage, elephantiasis 
and lymphous discharges co-existing. Occasionally, 
we find lymph-scrotum and elephantiasis of the leg 
in the same subject; and in cases of elephantiasis 
of the scrotum we may elicit a history of previous 
lymph-scrotum. Further, removal of a lymph-scrotum 
is sometimes followed by development of elephantiasis 
of a leg. Once, I have seen amputation of an ele- 
phantiasis of the scrotum followed, after many years, 
by the development of the vesicles characteristic of 
lymph-scrotum in the operation flaps.* These things 

Eor abundant illustrations of these diseases, alone and 
variously combined, and their connection with the filaria, the 
reader is referred to chapters ii., iv., and v. of this volume, 
and to the "China Customs Medical Reports," Nos. 2, 3, 8, 13, 
14, 18, and 23 ; also to an excellent paper by Dr. Y. Carter in 



PATHOLOGICAL SIGNIFICANCE. 23 

occiu* too frequently to be mere coincidences ; and 
if we reflect that both lymph- scrotum and ele- 
phantiasis are diseases of the lymphatics, that they 
are endemic in the same countries, and aft'ect the 
same part of the body, we must conclude that they 
acknowledge the same cause ; and this being proved 
to be i\\Q, filaria sanguinis hominis in lymph-scrotum, 
it must be the filaria sanguinis hominis in elephantiasis. 

It has been objected by some that because cases 
of elephantiasis occur sporadically in countries wher< 
the filaria is not endemic, therefore the filaria cannot 
possibly be the cause in these particular cases, and, 
inferentially, of those in countries in which the 
disease is endemic. But in answer to this, it is 
advanced that the mere presence of the parasite in 
a man's lymphatics does not necessarily produce the 
disease ; it only does so when it gives rise to obstruc- 
tion of the vessels, and anything that gives rise to 
similar obstruction may give rise to elephantiasis. In 
Europe, where the disease is exceedingly rare, it 
may be something else ; in the tropics, where it is 
exceedingly common, it is the filaria. 

Another objection to the parasite theory is found 
in the fact that the animal does not always give rise 

the " Medico-Chirurgical Transactions," vol. xlv. 1862; and to 
another paper, by the same author, on " Yarix Lymphaticus, its 
Co-existence with Elephantiasis," in the " Transactions of the 
Medical and Physical Society of Bombay," 1861, 1862 ; to Sir 
Joseph Fayrer's " CHnical Surgery in India ; " to " Elephan- 
tiasis Orientahs," by Allan Webb, M.D., " Indian Annals of 
Medical Science," No! 4, April, 1855 ; and to " Eemarks on 
Varix Lymphaticus orNsevoid Elephantiasis," by Surgeon K. 
McLeod, A.M., M.D., "Indian Medical Gazette," August 
1st, 1874. (See chap, v.) 



24 THE FILARIA SANGUINIS HOMINIS. 

to elephantiasis, and that the subjects of elephantiasis 
do not always, or generally, carry the embryos in 
their blood. How it comes to pass that the animal 
does not usually give rise to disease has been shown 
already ; how it does give rise to disease in certain 
cases, and why it is that giving rise to disease the 
embryos of the parasite do not always appear in the 
blood, I will now proceed to show. 

Lewis, describing the progress of the development 
of the embryo filaria in the uterus of the parent, says, 
that the immature animal does not burst its chorional 
envelope, but that it stretches this, so that after a 
time, and before it escapes from the vagina of the 
parent, its shell becomes its sheath. I have not had 
an opportunity of watching this in the case of the 
human parasite, but I have frequently watched an 
identical process in the case of filaria corvi torquati, 
a hsematozoon inhabiting the pulmonary artery of 
the common crow of South China. As the embryo 
nears the vaginal end of the uterine horns by 
dint of vigorous movements it gradually separates 
the poles of the ovum ; and before it emerges 
from the parent it has extended them so far 
that the originally round or oval sac has become 
converted into a sheath closely applied to the body, 
the superfluous covering dangling from the head 
or tail.* Lewis's observation is doubtless correct, 

* This stretching of the chorion is very easily demonstrated 
in the parasite I refer to. A crow is selected in whose blood 
the embryo filaria has been found; the sternum is thrown 
back, and the heart drawn forward by a hook transfixing 
the ventricles ; the pulmonary vessels are then put on the 
stretch, and cleared for some distance of lung-tissue by 



PATHOLOGICAL SIGNIFICANCE. 



25 



and is thus fully borne out by analogy. ITow, 
if from some cause or another the embryo filaria 
sanguinis liominis should be hurried into the lymph 
before the stretching of the chorion commences or 
is far advanced, what will be the consequence to 
the human host? In its unextended condition the 
ovum measures -gJo-in. X ygo-in-? or thereabouts. 
Its smallest diameter is thus five times greater than 
that of the fully-formed outstretched embryo we 
usually encounter in the lymph and blood. It is 
not too large, however, to pass along the vessels ; 

scraping with a blunt knife or the handle of the scalpel. 
The vessels should then be divided as deep in the lungs as 
possible. As a rule the parent filariee will protrude from 
the cut ends, or, if they do not, they can easily be found 
by slitting up the vessels. Half a dozen are often found 
together twisted into a sort of rope. A pregnant female — 
recognized by her large size and plumpness — should be selected, 



® 




Stretching of chorional envelope by the embryo <A filaria eorvi torquati. 

and her body divided at a point a little behind the vulva, 
which lies within an eighth of an inch of the mouth. 
Embryos and ova will escape, or can be expressed from the 
severed uterine tubes. Under the microscope they exhibit 
the movements I describe — the embryo actively employed 
in stretching the enclosing bag. By a little searching 
specimens at all stages, from the spherical ovum to the fully- 
stretched embryo, can be found. 



26 THE FILARIA SANGUINIS HOMINIS. 

but wlien the lymph-stream has carried it to the 
glands it is immediately arrested, for there the 
afferent vessel breaks np into many very minute 
branches which end in the solid parenchyma of 
the gland. The imprisoned embryo has no power 
to aid its onward progress ; but the egg lies like an 
embolus, passive, plugging the vessels and damming 
up the lymph. There will then be complete stasis 
of lymph in this particular vessel as far back as the 
first anastomosing lymphatic. Along this the current 
will now pass carrying with it other ova; these, 
in their turn, will be arrested at the first gland they 
reach. And this process of embolism, stasis of lymph, 
diversion of current into anastomosis, will go on until 
the whole of the lymphatic glands, directly or in- 
directly connected with the vessel into which the 
parent parasite ejects her ova, are rendered impervious, 
provided the supply of embolic ova is sufiicient, kept 
up long enough, or renewed from time to time. 

This reads like a piece of sensational pathology, 
but I do not describe what I have not seen. On two 
different occasions (and from different individuals), I 
have obtained the ova of filar la sanguinis hominis from 
the lymphatics ; once from the groin-glands of a case 
of lymphatic oedema of the legs,* once in lymph 
exuding from a lymph-scrotum, "f* Cobbold, too, and 
possibly Salisbury, have found ova, presumably of the 
same parasite, in the urine. The ova obtained from 
the case of lymph-scrotum must have come from a 
parent on the distal side of the groin-lymphatics. 
She must have been miscarrying for some time. The 
fact of embryos being found in the blood shows that 

* Case XXIV. p. 130. t Gase XXV. p. 131. 



PATHOLOGICAL SIGNIFICANCE. 27 

they must have had not very long before free access 
to it ; but as the number of them was very small, 
and even these disappeared just before the operation, 
embolism of the circle of glands must have been com- 
pleted. The ova found in the lymph were part of the 
crowd effecting this. This worm had lived in the 
patient's lymphatics for at least thirty-two years. 
When seen he was fifty years of age ; his scrotal 
disease commenced when he was only eighteen. In 
such a lifetime, and in an animal whose reproductive 
powers are so active, the chances of some irregularities 
in parturition occurring once or oftener must be 
considerable. These cases prove, at all events, that 
the filaria does at times miscarry. What has hap- 
pened twice or thiice happens oftener. If we reflect 
on the long life of the parasite; the activity of its 
generative functions ; the exposed position it often 
occupies in the legs or scrotum ; its liability to 
injury, therefore, from mechanical violence ; of the 
sicknesses of the host, his fevers and blood-poisonings*; 
the miscellaneous foods he consumes, some of which 
may act on the uterus of the worm as they act on that 
of the human subject ; we can readily understand how 
abortion is brought about. We know the mature 
parasite sometimes dies ; what kills her, applied in a 
less degree, may readily cause her to abort. 

* The exanthematous and malarial fevers are well known 
to be causes of abortion in the case of the human female. May 
they not similarly affect the female filaria ? Certain writers, 
especially Dr. Allan Webb, maintain very strongly that 
syphilis is one of the most common causes of elephantiasis. 
May not the explanation of this circumstance (if it is true) 
be, that the syphilitic virus operates on the uterus of the 
filaria as it is so well known to do on the human uterus ? 



28 THE FILARIA SANGUINIS HOMINIS. 

Of course it is impossible to prove in every case 
of lymphatic obstruction that this has been brought 
about by embolic ova. It must be a rare thing to see 
the patient at the proper time ; yet, if only once or 
twice we get the hint of the modus operandi,^ it is 
readily appreciated and the effects comprehended. 

The particular form of lymphatic disease, and the 
place affected, will depend on the position occupied by 
the parent worm, on the number of immature ova she 
ejects, on the frequency with which these miscarriages 
are repeated, and on the nature of the tissues involved, 
and individual peculiarities and accidents. 

Let any one with a diagram of the lymphatics 
before him in imagination locate an aborting female 
filaria in different situations, and follow out the course 
her embolic ova would take, and the effect of stasis of 
lymph, complete or partial, on the different lymphatic 
areas. If he bears in mind the influence of gravita- 
tion, and of inflammation readily induced in tissues 
whose vessels are congested, he will find that he has 
got a key to all the elephantoid diseases, and the 
apparent anomalies in theii* connection with the 
filaria. 

Suppose we locate her in the lymphatics of the 
right leg. Her ova will be carried first to the right 
inguino-femoral glands. After these have been 
plugged, more or less effectually, anastomosis will 
carry the ova by the scrotal and neighbouring 
lymphatics to the inguinal glands of the left side ; 
and when these, in their turn, have been effectually 
plugged, there must be complete stasis of lymph 
in both legs and in the scrotum. Perhaps the 
lymphatics of the latter, overstretched and varicose 



PATHOLOGICAL SIGNIFICANCE. 29 

from having had to carry the lymph of the right leg 
as well as that normally passing through them, give 
way ; there is then a lymph-scrotum producedj and 
in the fluid periodically escaping the young of the 
parasite or its ova may be found. Not having 
passed through any glands the lymph will be clear 
and straw-coloured as it is at the radicles. Perhaps 
the scrotal lymphatics, being strong and well sup- 
ported by a powerful dartos and thick skin, may not 
give way ; the lymph will then accumulate there, or 
gravitation may determine it to a leg, or both legs ; 
or all of these parts, as not unfrequently happens, 
may enlarge. In such a case, there being little or 
no circulation of lymph, probably the parent will 
die. 

If the worm is located in the scrotum much the 
same effects will ensue. But if she is in a lymphatic 
trunk of the pelvis or lumbar region, then, should 
the stasis caused by the ova involve the lymphatics of 
the kidneys, ureters, or bladder, chyluria may follow. 
As the parasite in this case is probably betwixt two 
glands, and as the anastomosis of the vessel in 
which she lies is guarded in all directions by 
glands, it may be impossible, if all of these are 
plugged, for embryos to get into the circulation. 
Generally, owing to the richness of the anastomosis, 
the plugging is not complete, and the parent sur- 
vives ; on the degree of obstruction, therefore, will 
depend the presence or absence of embryos in the 
blood. In addition to producing more or less com- 
plete stasis in a particular region, such an accident 
among the lumbar or pelvic lymphatics must diminish 
the number of vessels available for the transmission 



30 THE FILARIA SANGUINIS HOMINIS. 

of the lymph from the legs and scrotum. SiqDpose the 
obstruction is on the left side, and is extensive, then 
there must ensue regurgitation through unplugged 
glands, passage of lymph by anastomosis — either 
inside or outside the pelvis — to the right side, where 
perhaps alone lymph-paths are open. These are not 
sufficient for all the fluid that is formed in those 
parts lying below the seat of obstruction. Conse- 
quently there is increased pressure in the lymphatics 
of the legs and scrotum, and liability to lymph- 
scrotum or elephantiasis. Should lymph-scrotum 
result, then, as the lymph that escapes must have 
regurgitated through several glands, some of them 
possibly connected with the alimentary canal, it will 
be chylous, or even sanguineous. 

When once there is permanent stasis of lymph in 
a part, or a lymphorrhagia is established, there is 
relief afforded to the remaining lymphatics implicated 
in the original area of obstruction ; for the amount of 
lymph to be transmitted is less by the amount of 
that formerly sent from the seat of the developed 
elephantiasis or lymph-scrotum. This explains why 
excision of a lymph-scrotum is so frequently followed 
by elephantiasis of a leg, or by chyluria. The lymph- 
scrotum hitherto, up to the time of the operation and 
healing of the wound, acted as a sort of safety valve. 

The accumulation of a chylous fluid in the tunica 
vaginalis, called by Yidal " galactocele," is frequently 
associated with filarise in the fluid and in the blood, 
and is explained by the parent parasite being located 
in the lymphatics of the cord; or, by these partici- 
pating in lymph-stasis produced by obstruction in 
glands situated higher up the lymph-circulation. The 



PATHOLOGICAL SIGNIFICANCE. 31 

double enlargement of the inguinal glands in one- 
sided elephantiasis is also explained, as is also the 
so-called metastasis of this disease. 

And now my reasons for supposing I would find 
the parent filaria in the scrotum shown the Society- 
can be understood. The lymph was clear, thin, and 
straw-coloured, therefore there had been no regurgita- 
tion through the inguinal glands ; and as no embryos 
could be found in the blood, therefore, those that 
appeared in the scrotal lymph must have come from 
a parent on the distal side of the inguinal glands, 
possibly in the scrotum. 

It is unnecessary to follow out the argument at 
greater length. Enough has been advanced to show 
in what way all the phenomena of elephantoid disease 
may be explained by the theory that the parent 
parasite is the prime cause, premature birth of the 
ovum the second, and impaction of the lymphatic 
glands by the ova the immediate cause. 

The impossibility of permanent and thorough cure 
of elephantiasis is apparent. Much may be done by 
the knife to remove deformity, and elastic bandaging 
and other devices for aiding the lymphatics still 
patent and the blood-vessels to carry off stagnant 
fluid ; but permanent cure of the established disease 
is impossible. 

The prospect on the side of prevention is much 
more hopeful; for, if people in countries where the 
filaria is endemic would but cover their wells or 
water jars with a netting sufficiently fine to keep out 
the mosquitos, or if they filtered or boiled their 
drinking water, they would never get the filaria or 
the disease it produces — elephantiasis. 



CHAPTEE II. 

FILARIAL PEEIODICITY.* 

It had always seemed strange to me that the filaria 
sanguinis hominis had escaped observation in the blood 
until Lewis found it there in 1872. One would 
think there were hundreds of workers in India, and 
in different parts of the tropical world, who must have 
searched the human blood in the aggregate thousands 
of times; yet, notwithstanding this, the parasite, 
which in some places is present in every tenth 
individual, was overlooked or never found for so 
many years. The explanation of this I now offer. 
Most workers with the microscope, at all events in 
hot climates, pursue their investigations during the 
hours when the light is good — that is, during the 
day. It will be seen from the following remarks 

* "China Customs Medical Reports," xxiii. p. 36. "We 
are indebted to Cobbold for this very apt expression. 



FILATMAL PERIODICITY. 33 

that tliis is the wrong time to search for filar ia mn- 
guinis hominis. 

Two years ago, writing on the habits of filaria 
sanguinis hominis^ I remarked that in filarious 
patients the embryos were frequently temporarily 
absent from the blood. I was not aware at that time 
of any law governing this. My examinations were 
usually made in the early morning, or late in the 
evening ; and of the two assistants I employed, one 
worked during the day, the other after six o'clock 
in the evening. I remarked that the former made 
very few finds in comparison to the latter, but 
attributed this to accident. Several months ago I 
gave directions for a filarious patient's blood to be 
examined daily, and a register to be kept of the 
examinations. On some days there appeared to be 
great abundance of filarise, on other days none, or 
very few. I noticed that when they were abundant, 
the examination was made on busy days, when there 
was much work to be done in the hospital, and extra 
work of this sort had to be got through in the 
evening ; and that when they were absent, the exami- 
nation was made during the day. Eecollecting the 
different results obtained by my assistants, according 
as they worked during the day or after dark, and 
suspecting now that this was not altogether accident, 
I made a series of systematic observatious every four 
hours in this patient, and in others, with the view of 



34 THE FILARTA. SANGUINIS IIOMTNIS. 

ascertaining if this periodicity was maintained in 
every case. I examined a number of patients in this 
way with the result of finding that unless there is 
some disturbance, as fever, interfering with the 
regular physiological rhythm of the body, filaria 
embryos invariably begin to appear in the circulation 
at sunset ; their numbers gradually increase till about 
midnight ; during the early morning their numbers 
become fewer by degrees, and by nine or ten o'clock 
in the forenoon it is a very rare thing to find one in the 
blood. Till sunset they appear to have completely 
deserted the circulation ; but with the evening they 
come back again, to disappear in the morning; and so 
on with the utmost regularity every day, and from 
day to day. The circle is completed every twenty- 
four hours, and there are no longer spells of absence, 
as I at one time supposed, than from morning to 
evening. 

Subjoined is a register of some of the examinations 
from which I have drawn these conclusions. I have 
to apologize for the incompleteness of the series of 
observations in some of the cases ; but I often found 
it very difficult to get a Chinaman to submit during a 
number of days to the necessary manipulations, and 
consequently the evidence is fragmentary. But the 
numbers, taking them together, are quite sufficient to 
justify my deductions. 






O 



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a 






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2 .a 



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TsAO, chair coolie. \ 
Recent inflamma- / 
tion of cord and i 
testicle. J 


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scroti and lymph--; 
scrotum. 


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40 THE FILARIA SANGUINIS HOMINIS. 

These figures are abundantly sufficient to establish 
the diurnal periodicity of the embryo's appearance in 
the blood. For the meaning of it we have not far 
to look. The nocturnal habits of filaria sanguinis 
hominis are adapted to the nocturnal habits of the 
mosquito, its intermediary host ; and this is only 
another of the many wonderful instances of adapta- 
tion so constantly met with in Nature. 

On establishing this fact these questions occurred 
to me: — 1st. Is the disappearance of the embryos 
brought about by their death, and have we therefore 
a fresh swarm every twenty-four hours ? 2nd. If they 
do not die, where do they conceal themselves during 
the day ? 3rd. Has this periodicity any pathological 
significance ? 

With regard to the last of these questions I can- 
not yet give any answer. One could speculate very 
ingeniously with this for a starting point, but as yet 
I have no fact of any importance to offer. My con- 
viction is that the pathological significance of filaria 
sanguinis hominis in tropical disease is as yet by no 
means fully understood, nor the importance of the 
parasite completely apprehended. 

To get an answer to the other two questions, being 
denied the privilege of post-mortem examinations 
of men, I turned to the dog, and tried to gain 
some light from a study of the behaviour of the 
analogous canine hsematozoon, filaria iimnitis. First, I 
endeavoured to ascertain if there is any periodicity of 
a similar kind observed by the embryos of filaria 
immitis. I examined a number of dogs with this 
object in view, and the subjoined table is the 
rcfeult : — 



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t-i CO o r- »ci 

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Black and tan j 
terrier. | 


Black and tan ) 
terrier. i 


a) 


Setter ^ 



FILARIAL PERIODICITY. 43 

From this it appears that there is a certain period- 
icity, though not so perfect as in the case of filaria 
sanguinis hominis. Embryos are never entirely absent 
from the blood of infested dogs, though theii' num- 
bers are always greater during the evening and 
night than during the day, the period of greatest 
scarcity being from 9 a.m. to 1 p.m. This period- 
icity has doubtless in the dog, as it certainly has 
in man, reference to the habits of the interme- 
diary host. One might express it thus : — As 
regards their hsematozoa, in dogs there is dui-ing 
the day a remission in numbers, in men an 
intermission. 

Hoping from a post-mortem examination to get 
some information as to what became of the embryos 
during the period of remission, I procured a large 
Chinese dog, and for a few days made a preliminary 
study of the habits of his blood-parasites. But the 
brute was so wild, and in such a continual state of 
excitement, that the regular remission in the num- 
bers of the embryos was much disturbed, just as 
would happen from fever in man. The following is 
the register of embryos in a single drop of blood from 
the ear, drawn at the hours indicated on successive 
days : — 



44. 



THE FILARIA SANGUINIS HOMINIS. 



pq 





r s 


:::!!! 00 ! ; 










o 








OD 


>o o . cq --i . ^ o 
T-H CO »-i CO i-t o\ 


00 


. O . . CD . . . 


c^ 


>o 

.CO 


CD 








10 


. 1^ 05 

. <M O 

lO Its 


"^ 


Oi ^ t- . . . GO . 

■-1 o o . • . . C<1 


CO 


; . . CO . . o . . 


(M 


o cq 

' 00 lO 


iH 


■* (M Cq 

CO CO 


< 


r <M 








r-l 
i-l 


. t^ 


o 


. (M TiH CO 

. CO Cq 05 . . 
CO Cq- rH 


05 


O IM i-i . 

^ (M CO 


00 


00 -+I lO 

<M ; >o 05 : : : : : 


t' 


1—1 


CO 


: : : . o>- : . oo 


10 


~ . . . . . . >o 00 

:.::.. CO 0^ 


'* 


<M 


CO 








<s 








r-l 





FILARIAL PERIODICITY. 45 

It appeared from this that the embryos were 
fewest latterly in the early morning. Accordingly 
I selected one morning at six o'clock, when the 
embryos in a drop of blood numbered only eighty- 
two, to administer a dose of prussic acid. The heart 
was found to contain . four female and three male 
filarice immites. Of the four females three were 
found to be crowded with embryos at all stages of 
development, whilst in one the uterine tubes were 
found to be quite empty, save for a few dead embryos 
near the vaginal opening and the dehris of a former 
pregnancy. In the oesophagus were two large filaria 
sanguinolenta sacs full of parasites, and in the 
thoracic aorta were many small sacculations and 
sanguinolenta tumours. Slides of blood or fluid 
expressed from the following organs — each slide 
amounting to about one drop — contained embryos 
in the following numbers : — 

Blood from ear before death 82 

„ liver after „ 324, 365, 204 

„ lungs „ „ 4,582, 1,591, 2,738 

„ „ spleen „ „ 32 

„ „ kidney „ „ 

A second dog was killed, strychnine being used 
instead of prussic acid. Four female and three male 
filarise were found in the right ventricle, and in 
the oesophagus one immature sanguinolenta tumour. 
Slides of blood gave a very similar result to that 
obtained in the first dog. !N^o examination of blood 
before death could be made. 



Blood from mesenteric vein after death 


123 


„ „ lungs „ „ 


2,631 


liver „ „ 


53 



46 THE FILARIA SANGUIXIS HOMINIS. 

Blood from portal vein after death 219 

„ „ kidney „ „ 7 

„ ,, vena cava inferior after death . . . 270 

„ „ right ventricle „ ,, ... 501 

„ „ spleen „ „ ... 

,, ,, left external jugular vein ... 272 

Taken in conjunction with the register of embryos 
free in the blood at different times of the day, I 
conclude from these figures that the embryos of 
filaria immitis do not die or disappear after a short 
existence of less than twenty-four hours, but that 
they rest periodically in the minutest branches of 
the pulmonary artery ; and that when they disappear 
from the general circulation they are to bo found in 
the lungs. How they manage to maintain their 
position there against the blood-current I do not 
certainly know, but I suppose they attach themselves 
to the inner surface of the yessels in some way, 
possibly using their oral extremity as a sucker. 
Occasionally I have seen an embrj^o thus attach 
itself to a slide while under examination with the 
microscope. 

I think there can be little doubt that something 
similar happens in the case of filaria sanguinis hominis 
to what I have shown happening in the case oi filaria 
immitis, and that during the period it is temporarily 
absent from the general circulation it lies resting and 
waiting for sunset in some of the thoracic or abdominal 
viscera. What the particular organ is it selects has 
yet to be ascertained ; but this could easily be done 
by a microscopical examination of the viscera of a 
filarious subject dying of a non-febrile disease, or 
suddenly, during the day. 



riLARTAL rERTODICITY. 47 

Filarial Periodicity — Continued. 

In a former issue of these reports* I pointed out 
that singular phenomenon in the history of filaria 
sanguinis hominis^ which has come to receive the 
name oi filarial periodicity . I therein gave part of the 
evidence on which my assertion of the existence of 
such a phenomenon was founded ; and I ventured to 
make some suggestions as to its meaning in relation 
to the life-history of the parasite, and as to what 
becomes of the animal during its temporary absence 
from the general circulation. Although the evidence 
was somewhat fragmentary, ^^et, taken in connection 
with a multitude of unsystematic and unrecorded 
observations, it appeared quite conclusive, at least 
to my mind. However, in order to elucidate the 
subject, and render the evidence still more complete, 
I determined to avail myself of the first suitable 
opportunity to prosecute systematic observations ex- 
tending over a period much longer than that of any 
of the cases recorded in my previous report. Seeing 
that the periodicity is one of twenty-four hours 
I thought it possible that it might in some way be 
influenced, or even caused, by the more or less 
regular diurnal fluctuations in meteorological condi- 
tions dependent on the daily revolution of the earth ; 
or, possibly, that the normal daily rise and fall of 
body temperature, or other quotidian physiological 
phenomenon, might have some association with it. 
I determined, therefore, to add to my observation 
on the ingress and egress of the embryo parasites 
others on the temperature and pressure of the 

* "China Custrmis Medical Reports," xxiii. p. 1. 



48 THE FILAPJA SANGUINIS HOMINIS, 

atmosphere, the temperature of the body, and the 
rapidity of the circulation as indicated by the state 
of the pulse. 

I was able during the summer of 1880 to enlist 
the services of two sufficiently intelligent lads in 
every way well suited for my purpose. I trained 
them to examine the blood, to count the embryo 
parasites they found therein, to read the thermo- 
meters and barometer, and to record all their 
observations accurately. As they themselves were 
iilarious, and the subject of their own observations, 
the work could be prosecuted easily, with little fear 
of interruption, and with the sympathies of the 
observers entirely on the side of accuracy and 
truth. Their work I constantly superintended and 
checked. If error has crept into the chart* into 
which I have condensed their observations I am 
certain it is of a trifling and unimportant cha- 
racter, such as is necessarily inseparable from work 
of the kind ; taken as a whole, it may be thoroughly 
relied on. 

Both lads came from Hooihoah, a highly filarious 
district about three daj^s' journey to the north of 
Amoy. Li Kha (I. in the chart) was twenty-one years 
of age, of average size, and in good general health. 
He gave no history of fever, lymphangeitis, or 
of any serious disease whatever, and his body 
appeared to be free from blemish that might be 
associated with the presence of filarise. Tiong Seng 
(II. in the chart), on the contrary, gave a history 
that distinctly pointed to filarial infection. He, too, 

* This chart is reprinted from the " Journal of the 
Quekett Microscopical Club," vol. vi. 1881. 



FILARIAL PERIODICITY. 49 

was twenty-one years of age, and in good general 
condition, but lie stated that for six or seven years 
he had been subject to attacks of what he called ague 
(lymphatic fever), and that these attacks recurred 
about once a month. They began, he said, with a 
feeling of giddiness, and painful aching weariness 
in the body and limbs. This gradually merged into a 
cold stage of two or three hours' duration, which was 
succeeded by a hot stage of very high fever lasting 
for twenty-four hours and terminating in a moderate 
diaphoresis continuing for an hour or two. The 
fever was accompanied by complete anorexia, and 
during its continuance the inguinal and femoral 
glands invariably became swollen and excessively 
painful, those on the right side being more affected 
than those on the left. With the exception of these 
attacks, and an orchitis which developed while under 
observation to be presently alluded to, he never had 
any trouble about the limbs or genitals, nor other 
symptom of filarial disease. 

The observations by and on these two men I con- 
densed and arranged in Chart I. In explanation of 
it I may mention that the first three compartments, 
counting from above downwards, refer to Li Kha 
(L); the second three to Tiong Seng (II.) ; and that 
the two lowest are occupied by readings of the baro- 
meter and ordinary thermometer. At the left hand 
margin are numbers referring to the filarise found 
in a droplet of blood obtained by pricking the finger, 
and sufficient to occupy in a thin transparent film a 
slide measuring 1-in. X IJ-in. ; also the degrees of 
temperature of the body, beats of the pulse per 
minute, temperature of the atmosphere, and baro- 

E 



60 THE FILARIA SANGUINIS HOMINIS. 

metric pressure. Along the top the figures refer to 
the date and hour of the day at which the examina- 
tions were made. 

This chart, recording as it does a long series of 
systematic and carefully-made observations, estab- 
lishes thoroughly my first assertions about filarial 
periodicity. A glance at it shows with what regu- 
larity every evening the embryos enter the general 
circulation, how they increase in number up to mid- 
night, and how, as morning approaches, they gradu- 
ally diminish until they completely disappear. Rarely 
can one be found from nine a.m. until six p.m., at least 
under ordinary circumstances. Since these observa- 
tions were made I have had the satisfaction of seeing 
them confirmed by several others ; notably, by Dr. 
Myers in Formosa,* and by Dr. Stephen Mackenzie 
in London.f Drs. Eennie and Adams of Foochow, I 
understand, can also confirm my statements ; and I 
doubt not that by this time filarial periodicity has 
been amply demonstrated by other observers in the 
diiferent countries in which the parasite is endemic. 

It is a remarkable phenomenon ; and now that its 
existence is so well established I would commend it 
to the physiologist as a possible aid to the explana- 
tion of such rhythmical phenomena as sleep, the 
evening rise of body - temperature, etc. ; to the 
pathologist as a possible aid towards the explanation 
of diurnal intermission and remission in fevers, 
especially of the ague class. Whether it may or 
may not be of service in either of these directions it 

* " Customs Medical Eeports," xxi, 7. 
t "Lancet," 1881, ii. 398, 707. "Transactions of the 
Pathological Society of London," 1882, vol. xxxiii. 



FILARIAL PERIODICITY. 51 

is impossible as yet to say. But though it may lead 
to nothing in this way, yet the thing itself is so 
curious and of so striking a character that the mind 
naturally desires more information about it, and, if 
possible, an explanation of its object and of its 
cause. 

I have already pointed out* that filarial periodicity 
is an adaptation of the habits of the filaria to those 
of the mosquito, the intermediary host indispensable 
to the future life of the parasite. ' This is the object 
of the arrangement ; but the particular force or 
mechanism that operates on the embryo parasite, 
causing it to appear in the blood normally only at 
certain hours, — this, the cause of filarial periodicity, 
has yet to be ascertained. Certain facts, however, 
have recently been discovered that tend to confine the 
search to a comparatively'- limited field. 

From the fact that the periodicity is one of twenty- 
four hours we are justified in inferring that its 
remote cause is the diurnal revolution of the earth. 
As affecting the parasite in the human body this 
may operate in one or two ways : 1st, by means of 
some of the daily and rhythmical variations it pro- 
duces in meteorological forces — one or other of these 
being the direct determining influence that liberates 
or restrains the parasite ; or, 2nd, by inducing 
in the host of the parasite certain quotidian and 
rhythmical habits on which, directly or indirectly, 
the movements of the hsematozoon depend, — such 
as the habits of waking and sleeping, exercise, the 
evening rise of body-temperature, the times of 
feeding, etc. 

* Page 40. 

e2 



52 THE FILARIA SANGUINIS HOMINIS. 

With regard to the first of these, there are at 
least four principal meteorological phenomena which 
have a more or less quotidian and rhythmical charac- 
ter, and which one might conceive had an influence 
in some way on the parasite. These phenomena are 
— the rise of atmospheric temperature during the 
day and fall during the night ; the decrease of 
atmospheric pressure during the afternoon ; the 
coming and going of the light ; and the diurnal 
variations in the electrical condition of the earth, as 
indicated by the magnetic needle. But if we inquire 
into the behaviour of any of these we shall find that 
no one of them is so absolutely true in its rhythm as 
is filarial periodicity. There are frequent exceptions 
to the general rules that the day is warmer than the 
night, and that barometric pressure falls during the 
afternoon. If either of these things, therefore, had 
anything to do with filarial periodicity, then we 
should expect to find the latter in entire sympathy 
with one or other of them, and exhibiting corre- 
sponding variations. But if Chart I., in which these 
are carefully noted, is consulted, it can be seen at a 
glance how far this is from being the case. The 
presumption is, therefore, that filarial periodicity is 
independent of atmospheric pressure and tempera- 
ture. 

To ascertain if the waxing and waning of the light 
had any influence, I had a filarious subject, in whom 
I had previously ascertained that periodicity was 
normal, shut up for several days in a dark room, into 
which it was impossible for a single ray of sunlight 
to penetrate. During four days, as far as sunlight was 
concerned, he was always in the dark, and it was only 



FILARIAL PERIODICITY. 



53 



after sunset that he left his room. A glance at the 
following table sliows that the result of this experi- 
ment was entirely negative. I may remark that I 
was careful not to interfere with his usual habits, 
and therefore did not disturb him during the night to 
examine his blood. It was sufficient for my purpose 
to ascertain approximately the hours of ingress and 
egress of the embryos, and their conduct during the 
day. 

Table showing the ^NTumber of Embryo Filari.e, at 
the Hours and Dates indicated, in a Slide of 
Blood 1-in. X l|^-in,, the Subject of Observation 
being kept in a Dark Eoom during the Four Days, 
November 26th, 27th, 28th, and 29th. 



Hour. 


Nov. 
24 


Nov. 
25 


Nov, 
26* 


Nov. 

27* 


Nov. 

28* 


Nov. 
29* 


Nov. 
30 


Nov. 
31 


Dec. 

i 


Dec. 

2 


7 A.M 

11 „ 


1 


5 
10 


4 




8 


13 
1 

1 





39 




18 


25 

1 

2 

1 

10 


19 





7 


17 
1 
3 
5 

17 


16 

1 
1 

18 


12 

2 
4 

27 


14 




16 


4 P.M 

7 „ 


9 „ 





* In dark room. 



Thus, of the meteorological influences which might 
be supposed to have an influence on filarial periodicity, 
three are eliminated. It has been shovvn that neither 
temperature, atmospheric pressure, nor light has any- 
thing to do with it. There remains only terrestrial 
magnetism ; but, although the rhythm of its variations 
corresponds very closely with that of filarial period- 
icity, the progress of discovery within the last few 
months has rendered a connection between the two 



54 THE FILAEIA SANGUINIS HOMINIS. 

-SO extremely improbable, that I have not considered it 
worth while to pursue investigation in this direction 
any longer. It has been pretty conclusively demon- 
strated that the immediate cause of filarial period- 
icity is dependent, not on meteorological conditions 
resulting from the daily revolution of the earth, but 
on the habits this great fact impresses on the human 
body. 

In the "Lancet" of August 27th, 1881, there 
appeared a letter from Dr. Stephen Mackenzie, in 
which he announced that a case of chyluria of Indian 
origin had occurred at the London Hospital, and 
that the filaria sanguinis hominis could be found in 
abundance in the patient's blood ; and, further, that 
the same periodicity was observed by the parasites in 
London as had been described as occurring in China. 
At the meeting of the Pathological Society on 
October 18th, Dr. Mackenzie exhibited this patient 
and demonstrated the parasites in his blood ; and he 
also described how he had been able to break up, and 
even invert periodicity, by simply changing the 
habits of the patient with regard to the times of 
sleeping and waking. If the patient slept during 
the day and kept awake during the night periodicity 
was inverted. This was a new and important fact. 
It seemed to be another step towards the explanation 
of a curious phenomenon ; and, impressed by its 
importance, I took an early opportunity to repeat and 
vary Dr. Mackenzie's experiments. 

The history of the first patient on whom I experi- 
mented is briefly as follows : — 

Case I. Filar ice in the hhod ; enlarged spleen; ancemia : 
dxperimeni on inversion of filarial periodicity. — Tin, male, 



FILARIAL PERIODICITY. 55 

aged twenty-five ; Tsongklise, Tchangtchiu ; a field labourer, 
Wlien twelve or thirteen years old, he says, lie had an abscess 
in his lungs, which burst, the contents escaping by his 
mouth. He spat over a bowlful of blood and pus at the 
outset, and continued afterwards for about four months to 
cough up similar stirff.* He says the matter expectorated 
was thick, viscid, and could be drawn out in a long string ; 
the discharge of this was difiicult, attended with much 
cough ; says he recollects this very well, as his mother used 
to slap his back to encourage expectoration. Now he has no 
trouble about his lungs beyond a slight cough when he 
catches cold. At fifteen or sixteen, had for four months an 
eczema on both legs, and at seventeen a very large abscess in 
the right popliteal space. Since boyhood has been subject 
every autumn to aguish attacks, of a very irregular character, 
lasting off and on for about a month every year. Often 
during these attacks the inguinal glands, sometimes on the 
right side, sometimes on the left side, inflame, but neither 
pain nor swelling is ever considerable. Occasionally his 
right testicle enlarges without inflammation. These attacks 
of fever consist of about one hour of rigor, followed by 
three hours of heat and one hour of sweating ; often they 
are distinctly tertian, and I think they are genuine ague. 
The swelling of the glands does not always accompany the 
fever, but the lymphangeitis is usually associated with fever. 

He states that some years ago I removed big scrota from 
two men living in his village, but he does not know of any 
well-marked case of elephantiasis of the leg among his 
neighbours. When young he often drank cold water, but 
since he became sick he never touches it. 

He is very thin, anaemic, and debilitated. An enlarged 
spleen extends beyond the border of the ribs. He has no 
decided enlargement of glands, scrotum, or legs ; nor does 
he give any history of chyluria. 

This year his ague began about two months ago. It was 

* In Dr. Stephen Mackenzie's case, just referred to, 
abscess, apparently connected with the thoracic duct and death 
of the parent filaria, formed as in this patient, 



56 THE FILAEIA SANGUINIS HOMINIS. 

tertian in type, and continued on him in a subdued form for 
about a montb. He came to hospital to be treated for his 
debility, enlarged spleen, and dyspepsia. He took quinine 
and Bland's pills for a fortnight, and when his health had 
improved considerably I got his consent to experiment on his 
blood-parasites. 

From the 9th to the 26th December, 1881, ob- 
servations were regularly made on this man, the 
usual quantity of blood (1-in. X l^-in. cover glass) 
being examined each. time. During the first five 
days sleep was indulged in at the usual hours. Period- 
icity having been found normal, the time of sleep 
was changed to the day, and of waking to the night. 
On December 14th he was not allowed to sleep as 
usual, but was kept awake till six in the morning of 
the 15th — that is, for twenty-four hours. He was 
then allowed to sleep till afternoon ; and from this 
time sleep was alwaj^s indulg'ed in during the day, 
while at night he was kept awake. Simultaneously 
with observations on the number of filarise present in 
a given quantity of blood, observations on the body- 
temperature were made in order to avoid the com- 
plicating effect of fever, should this occur ; but as the 
temperature kept normal all the time I have not 
considered it necessary to introduce its record into 
the chart (II., facing this page) on which I have 
condensed my observations. In explanation, I may 
mention that the figures at the side refer to the number 
of filarise in a slide of blood 1-in. X l^-in., while 
the figures along the top refer to the date and hour 
of examination. For the first five days the sleeping 
hours were from six p.m. to six a.m. On the sub- 
sequent days — that is, from the 15th to the 24th 



CHART II 

Hppvesonting the Effects of Day Sleepino and Nioht Watching in inverting Filarial Peeiodicjtv 



fv 



s 



-.lllj 



c- 



F=^ 



-A-^ 



h-u: 



I 



til 






A- 



■^L ■( i . ^vi^rn^TV 



1 



FILARIAL PErJOBiriTY. 67 

December — they were from five a.m. to five p.m. 
During tlie period when the patient slept at night I 
did not consider it necessary to wake him at midnight 
to sample his blood, so in the chart I have assumed 
that at this hour on these days the filariaj numbered 
100. With this exception, only carefully-observed 
facts are recorded. 

It is evident from this chart that Dr. Mackenzie's 
case was not exceptional ; it confirms his statement as 
to the connection of the sleeping and waking states 
with filarial periodicity. Something bound up with 
these states has clearly a powerful influence on the 
parasite or its young. But, as Dr. Mortimer 
Granville points out,* it is not simply sleep or 
waking that has this influence. It is something 
recurring every twenty-four hours, just as the habits 
of sleeping and waking recur, and which is capable 
of being inverted just as these habits are, and by the 
same means. That sleep does not cause the ingress 
of embryos is evident from the circumstance that 
ingress commences hours before the usual time for 
sleeping, and egress begins hours before the usual 
time of waking, and periodicity is maintained even 
though no sleep be indulged in for two or thi'ee days, 
or if sleep is continuous, or nearly so, for as long a 
time [sec Charts III. and IV.). The facts of the 
case seem to indicate that the conditions favourable to 
the ingress of the parasites become developed 
ordinarily during the last few hours of the waking 
state, and that they are slowly eliminated during the 
last few hours of sleep. 

Being anxious to vary Dr. Mackenzie's experiment, 
* " Lancet," 1882, i. 314. 



58 THE FILARIA SANGUINIS HOMINIS. 

and, if possible, obtain additional facts that might aid 
in answering the question of the canse of filarial 
periodicity, I placed two other men under observa- 
tion, and variously altered and modified their hours 
of sleeping, waking, and eating. Unfortunately, the 
man Tix, who was the subject of the observations 
recorded in Chart II,, had had enough of it, and 
seemed very reluctant to submit to a second course of 
experiment. I was therefore obliged to fall back on 
the two other men, whose stock of filariae was rather 
too limited to show distinctly delicacies of fluctuation. 
I give the results for what they are worth. Charts 
III. and IV. are arranged on the same plan as Chart 
I. The letter "F" is introduced at the hours when 
food was taken. 

In the case of Tiek Po (Chart III.)> the patient slept 
from nine p.m. on December 30th to six a.m. on the 
31st. From nine p.m. on December 31st to six a.m. on 
January 3rd, and from three p.m. on that day to three 
p.m. on the 5th, sleep was prolonged by repeated doses of 
chloral, the patient being waked up to take food at the usual 
hours. From the 5th to the 8th January the sleeping hours 
were from nine p.m. to six a.m. Thence until the 20th 
sleep was allowed each day from eight a.m. to noon, and 
from eight p.m. to midnight. On the 20th-21st the patient 
slept from eight p.m. to six a.m., and on the subsequent 
nights from nine p.m. to six a.m. 

In the case of In (Chart IV.), sleep was permitted from 
nine p.m. on December 30th to six a.m. on the 31st. 
The waking state was enforced from this latter hour until 
nine p.m. on January 2nd. Thence to January 18th sleep 
was enjoyed nightly from nine p.m. to six a.m., and from 
nine p.m. on the 18th to noon on the 19th. 

The history of the men is briefly as follows : — 

Case II. Tiek Po (Chart III.), male, aged twenty-five ; 



:, Pemodicitt. 
































9th. 


IOtx. 


Ktm 


I2tk 




r3Tx. 




AM 


P-. 


A.H. 


PM 1 


A.M. 


P.M. 


A.M. 


P.M. 




P.M. 




6 


9 " 




6 


9 




3 


6 


9 


.. 


3j6 


9 


,. 


3 6 


9 ■ 


" 3 


6 


9 13 


3 6 


9 • 


' 3 


6 


9 




3 


. 


9 




3 « 9 


I. 




F. 


F. 




F. 










F. 


r 


F. 








F. ! 




F. 






F. 


-. 


F. 










F. 


r 


F 


































































- 


- 




















































































t 














































































































































































































































































































































































































































































































































































A 




























V 


-• 


^ 


r* 


^ 






k 




-♦ 


, ^ 


..♦ 


-» 


"T^ 


-*L, 


►L«- 


-*■ 


-*i^ 


M 


4- 


»u 


u-» 




^ 


■» 


-• 


^ 


-'♦ 


-♦ 


.-• 


k* 


k*' 




24™. 


25th. 


laTH. 






P.K. 


A.M. 


p.-. 


A.M. 1 


P.M. 


- -^*-"- 


P.M. 




6 


9 


I. 


3 


6 9 


13 


3 


6 


9 


.. 


.3 


6 


9 


,. 


3 « 


9 ■ 


a 3 


6 9 ij 


3 * 


9 I 


= 


F 










K. 


F 




r 










f. 


F 


i: 








F. F 




































































































































































































































































































































' 




































































































t 


















/ 


s 
























/ 


\ 














r> 




^ 








/ 


--^ 












> 






^ 


^ 






-«r^ 






:^ 




^^j 


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CHART III 

Representing the Effects of Day Sleeping and Night Watching in inverting Filarial Periodicitt. 




CHART IV. 

Representing the Effects of DAT Sleeping and Night Watching in inverting Filarial rEiiioDU 



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FILARIAL PERIODICITY. 59 

Tchauoi, Tchiupo ; farmer. He lives in a village of about 
150 inhabitants, and among these are several cases of elephan- 
tiasis. Has been ailing for four or five years with ague of 
tertian type. Off and on has had attacks every winter with 
the advent of the cold weather. His spleen has been en- 
larged for several years, and since a year ago he has been 
subject to attacks of pain and swelling in the left testicle and 
cord. 

On examination his spleen is found to extend to the 
umbilicus, but no swelling of cord, testicles, scrotum, glands, 
or legs can be made out ; nor is there any history of 
ehyluria or lymphatic fever. Two months ago he had a 
single fit of fever, and is now very anssemic. 

During the time he was under observation he was given 
quinine and iron in full doses. 

Case III. In (Chart lY.), male, aged f ortj^-seven ; 
Tang-mng, Tchiupo ; farmer. In his village of 200 inhabit- 
ants are several cases of elephantiasis of leg or scrotum. 
One of the latter was operated on at the hospital some time 
ago. Since boyhood has been subject nearly every year to 
Ijonphatic fever of three or four days' duration, associated 
with swelKng of the testicles and scrotum. He has also had 
attacks of tertian ague and swollen spleen ; but at present 
both spleen and scrotum are normal to all appearance, 
although the groin-glands are rather large and firm. He 
says that during his fever attacks these glands swell to the 
size of fowls' eggs. Had, on admission, right facial paralysis 
of forty days' standing ; this supervened during an attack of 
fever and delirium. Has never had ehyluria nor distinct 
sign of elephantiasis. His reason for coming to hospital 
was to be cured of a long-standing chronic ulcer on the left 
leg. He, too, while under observation, took full doses of 
iron and quinine. • 

From these charts we may gather that filarial 
periodicity is maintained during prolonged watching ; 
and, also, when the hours of eating are changed, so 
that the middle meal is taken at midnight, and not, 



60 THE FILARIA SANGUINIS HOMINIS. 

as usual, at mid-day; also, that prolonged sleep 
j)ossibly disturbs periodicity, and diminishes the num- 
ber of jDarasites circulating at the time of maximum ; 
and, that when the usual alloAvance of eight hours' 
sleep is taken in spells of four hours at a time, at 
intervals of eight hours, periodicity is disturbed, and 
the numbers circulating at the time of maximum are 
sensibly diminished. 

When experiments and facts have been multiplied, 
we may be able to say precisely what is the cause of 
filarial periodicity. At present, facts are wanting. 
One which seems to me to have some importance I 
have not yet alluded to. If reference be made 
to Chart I., at p. 49, it will be seen that the man 
TiONG Seng was, shortly after observation com- 
menced, attacked with fever. The fever was conse- 
quent on orchitis and lymphangeitis undoubtedly of 
filarious origin. It will be seen that the body- heat 
1 was very high a considerable time before periodicity 
! was affected, and that the usual rhythm of the ingress 
and egress of the parasites was not renewed for some 
; days after the temperature had fallen to normal. It 
i would seem that the febrile state slowly developed 
j in the blood, or elsewhere, some constituent or con- 
dition whose presence or amount influenced the 
'. parasites, and that it was not until this pathological 
product or condition was eliminated or altered that 
\ periodicity of a normal character was resumed. May 
\ not the waking state, which seems so favourable to 
the ingress of the parasites, be associated with the 
development of some physiological condition or pro- 
duct analogous to, or the same as, that resulting in 
pathological quantity from fever, and the presence of 



FILARIAL PERIODICITY. 61 

which leads to the presence of the embryo parasites in 
the blood ? 

Dr. Mackenzie's discovery has done something to 
advance this interesting inquiry. He has limited the 
field in which search need be made. Nevertheless, 
much has yet to be done, more facts to be collected, 
before the answer can be given. It seems to me that 
this will have to be supplied by the physiologist ; and 
when the answer has been given, we shall be in 
possession of an explanation of many phenomena 
more important, though not more curious, than filarial 
periodicity. 



CHAPTEE III. 

DESTINY OF THE EMBRYO FILARIA PARASITES NOT 
REMOVED FROM THE BLOOD.* 

Another point on wliioli I have a few remarks and 
facts to offer lias recently been discussed by Dr. 
Myers in a valuable paper in the twenty-first volume 
of ''China Customs Medical Eeports," viz., the fate 
of the embryo parasites which have not been directly 
removed from the blood by mosquitos or other means. 
Do they, after a brief life of a few hours, die ; and 
have we to deal with a fresh swarm every twenty- 
four hours ? Or, do the parasites, after a temporary 
appearance in the general circulation, daily retire to 
some organ or set of vessels to await the recurrence of 
conditions, such as I have been discussing, which 
induce them again to circulate ? Dr. Myers alleges 
that when the blood is examined towards morning, 
when the numbers are diminishing, symptoms of 
languor are observable in many specimens; and if 
these languid individuals are watched for some days 
they are found to disintegrate more rapidly than other 
and more vigorous specimens obtained during the 
earlier part of the night. Dr. Myers's experiments I 
repeated many times, but failed to satisfy myself that 
what he describes applied to the parasites I observed. 
I have kept both morning and evening embryos alive 

* " China Customs Medical Reports," xxiii. 



DESTINY WHEN NOT REMOVED FROM BLOOD. 63 

on oiled slides for over 100 hours. In fact, so long 
as the serum of the blood remained fluid or viscid, so 
long did the parasites live. I do not think it reason- 
able to suppose that animalcules exhibiting such 
tenacity of life outside the body should so quickly die 
in it, seeing that the circulating blood is their natural 
habitat. But, even supposing that what Dr. Myers 
describes is to be found in every case, it does not by 
any means follow that this condition of languor is 
preliminary to disintegration ; quite as probably it is 
preliminary to their passing into some state of rest. 
If they died daily in the blood, surely dead specimens 
would be frequently met with ; yet so far is this from 
being the case that I do not recollect ever to have ; 
seen in freshly-drawn blood a dead filaria — at least,/ 
one whose death could not easily be accounted for by 
crushing under the cover glass. The facts Dr. Myers 
adduces are hardly sufficient to found an argument 
on. In a former page* I quoted some experiments on 
the destiny of the embryos of filaria immitis of the 
dog. Their preponderating abundance in the lungs at 
certain times seemed to favour the supposition that 
they occasionally retired to the pulmonary circulation, 
and I suggested that something analogous might 
happen in the case of filaria sanguinis liominis. I 
quite agree with Dr. Myers that such evidence is not 
conclusive, but analogy must be allowed to have some 
weight in inquiries of this nature. I may mention 
here that blood aspirated from the enlarged spleens of 
two filarious patients during the day contained no 
filarise ; and that examination of a very small quan- 
tity of lung-blood in a case of haemoptysis, also in a 
filarious subject, yielded similarly negative results. 
* Pages 45, 46. 



64 THE FILARIA SAj^^GUINIS HOMINIS. 

If we adopt Dr. Myers's view as to the fate of the 
bmbryos, we are driven to the conclusion that filarial 
jperiodicity depends on intermittent reproduction, and 
Ithat a fresh swarm issues from the parent every 
Jtwenty-four hours. It is possible to put this 
hypothesis to the test of experiment. In two cases 
I have had the opportunity of doing so. 

I have already* referred to a case of lymph-scrotum 
in which the parent filaria was found. Prior to 
operation lymph constantly dripped from ruptured 
- (jr^ lymphatics on the surface of the scrotum. As there 
-ji,\»*^ was constant discharge, there was no accumulation. 
7]V^. Therefore the lymph that escaped was a fair sample of 
1 %y what was passing the parent worm, and in which she 
I ***<>'* ^^® lyi^S- ^^^ lymph was examined three times in 
w^'-bne day, viz., at eleven a.m., five p.m., and seven p.m. 
, ^^At each examination many embryos were found. It 
was evident that the parent was giving birth to them 
at a time when they are normally absent from the circu- 
lation, and that periodicity in this case was independent 
of the act of parturition. Did filarial periodicity 
^/ depend on intermittent reproduction, then no embryos 
j^- could have been found at eleven a.m , and if found at 
five p.m. they would have been present in the lymph 
only in very small numbers. I might have made a 
more extended and careful series of examinations in 
this case with a view to settle the point, but its im- 
portance did not occur to me at the time. Still, as 
far as they go, these few observations are significant. 

Since Dr. Myers informed me of his views I 
have been on the outlook for a similar or equally 
suitable case, and some time ago succeeded in find- 
ing one which seems to me to settle ^^ point. 
* Page 1. See also p. 123, Case XXII. 



DESTINY WHEN NOT REMOVED FROM BLOOD. 65 

Case IV. Chyluria ; filarice in the blood and urine ; an 
attempt to ascertain tohether filarial periodicity he dependent 
on quotidian and intermitting reproduction, or ichether it he 
altogether independent of the act of parturition. — Ip, male, 
aged twenty- four ; born and residing in Hongsansia — a large 
village on the North River, about 8 po from Amoy ; farmer. 
Never suffered from fever, nor, until lately, from any 
serious disease. Sometimes has dyspeptic pains in the belly, 
but nothing of a more serious character. For the past 
seven or eight years has been troubled with swelling of the 
left testicle after a hard day's work ; the swelling is only 
sKght, and is never accompanied by fever or inflammation. 

The chyluria, on account of which he came to hospital, 
appeared about sixty days before the date of his admission. 
It began suddenly, after a long, rough, midnight hunt after 
wild pig on the Hongsan Hills. On his return home he 
urinated clots, and since then he has constantly, with only 
one or "two exceptions, passed chylous urine. Latterly, he 
says, the urine has become redder in colour; formerly it 
was more milky. 

He has no elephantiasis or disease of legs, scrotum, or 
glands ; the only thing amiss is slight swelling of the left 
testicle. Elephantiasis is not common in his village, but 
there are plenty of cases in the surrounding country. He 
often drinks cold water.* 

* The reader will observe that in the record of many of 
my cases I allude to the drinking of cold water by the sub- 
jects of filaria disease. I have been particular on this point, 
as some have asserted that the Chinese do not drink cold 
water at all ; and that therefore the action of the mosquito 
as intermediary host of the filaria, and of drinking-water as 
the medium by which the parasite gains access to the human 
host, must be a piece of imagination on my part. It is quite 
true that certain well-to-do and hypochondriacal Chinese 
avoid cold water, both for internal and external use, but the 
mass of the people have no such prejudice, at least as regards 
the internal use ; nor, if they had, could they afford to 
indulge it. Coolies and labourers of all descriptions must 
drink when thirsty, and they certainly have no time or 

P 



66 THE FILARIA SANGUINIS HOMINIS. 

The urine, on being passed, is of a dark opaque salmon 
colour, and reddish clots swim in it. Examined with the 
microscope it is found to contain many active fllarise, and 
his blood, if searched after sunset, is seen to be similarly 
infested. 

He complains of much debility and considerable loss of 
flesh and strength, but his appetite is as good as ever. 

As in this case lymph, or chyle was nearly always 
present in the urine, there could be no accumulation 
in the lymphatics. What at any given time might be 
selected for examination was a fair specimen of that 
passing the parent worm ; and the presence or absence 
of embryos in this would be a reliable indication of 
her activity or repose, as regards the act of partu- 
rition. It was therefore a case well suited to settle 
the question whether filarial reproduction was a more 
or less constant, or an intermitting process. 

The patient was given a placebo, and directed to pass 
urine into a clean vessel every three hours. The urine thus 
obtained was well stirred, so as to break up coagula as soon 
as they formed. An ounce of it was then drawn off into a 
smaller vessel, and allowed to stand for some hours until 
subsidence had occurred. A little of the sediment was then 
taken up with a pipette, one drop of this placed on a suitable 
slide, and the filariae it contained carefully counted. Blood 
drawn at corresponding hours was also examined, and the 
number of embryos in a sHde 1-in. x 1^-in. enumerated. The 
result of these examinations, extending over one week, I 
have projected in the accompanying table. 

opportunity to boil water on the roads and in the fields, and 
to wait till it cools before drinking. Boys and girls have 
none of the hygienic fads that may trouble their seniors, but 
gratify an appetite regardless of theory or consequence. I 
have made many inquiries about water drinking among the 
Chinese, and find that they are very much Hke other nations 
in this respect. 



DESTINY WHEN NOT EEMOVED FROM BLOOD. 



67 



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68 



THE FILARIA SANGUINIS HOMINIS. 









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DESTINY WHEN NOT REMOVED FROM BLOOD. 69 



If these figures are added together, and arranged 
as follows, the results of this examination become 
more apparent. It seems to me that they indicate 
that filarise embryos are nearly constantly passed into 
the lymph-stream ; and that whenever lymph finds its 
way into the urine, no matter at what hour, nor how 
long it has been running, it contains the parasite. 
Therefore, filarial periodicity is independent of the 
act of parturition, which is more or less a con- 
tinuous process. 

Precis of foregoing Table. 



V 





HOURS. 


3 

A.M. 


6 

A.M. 


9 

A.M. 


12 ' 

M. 


1 




3 6 

P.M. P.M. 


9 : 12 

P.M. MDN 


Total quantity of urine in 
ounces 


25 

4 

10 


144 

7 



11 

36 


55 

43 




75 

24 



90 

26 

1 


78A- -'^fi 


,, filaria3 in a slide of 
urine 


28 
62 


3 

50 


,, filarise in a slide of 
blood 




Average quantity of urine . . 
,, fllariag lq a slide of 

mine 

,, filariaj in a slide of 
blood 


6 
If 


2f 

li 



If 

6 




9* 



12| 
4 



15 

4| 

1 


13 

4| 

lot 


9| 

3 
6 

8| 






Number of times uriae watery 


4 


3 





1 


2 





1 



Although not bearing specially on the subject 
under discussion, the history of the case after this 
series of observations was completed is of interest as 
showing how much mechanical influences have to do 
in setting up and maintaining elephantoid diseases. 

The observations recorded in these tables were completed 
on August 19th. On the 20th I sent him to bed, and 



70 THE FILARIA SANGUINIS HOMINIS. 

confined him strictly to the recumhent position. Yery 
shortly this had the effect of making the urine in most 
specimens perfectly limpid. By the end of a week it "was 
permanently clear. He then went home. Six months after- 
wards I heard of him. He was then quite well, and said 
he had not passed chylous nrine since he left the hospital. 

The chyluria was caused in the first instance by the 
succussion of. rough exercise rupturing a congested 
and dilated lymphatic in the urinary tract ; rest, and 
the removal of lymph-pressure obtained by maintain- 
ing the recumbent position, allowed the rupture to 
heal. The chyluria was thus cured, at least tem- 
porarily, and one element in the pathology of these 
diseases clearly indicated. Chyluria, lymph-scrotum, 
elephantiasis, diseases caused by lymphatic congestion 
and varicosity, should be treated on exactly the same 
principles as diseases resulting from mechanical blood- 
congestion or venous varicosity. The most important 
element in the treatment of both forms of congestion 
is the removal, as far as possible, of fluid ]3ressure, by 
rest and elevation of the affected part. 



CHAPTEE lY.* 

THE FILARIA SANGUINIS HOMINIS AT AMOT, CHINA ; 
THE PROPORTION OF THE POPULATION AFFECTED ; 
THE INFLUENCE OF AGE, SEX. AND OCCUPATION; 
THE ASSOCIATED MORBID CONDITIONS. 

The following statistics and observations were made 
with, the view of ascertaining — 

1. The degree in which the general population of 
this district (Amoy) is affected with filaria sanguinis 
hominis. 

2. The influence of age, sex, and occupation in 
determining the presence of the parasite. 

3. The morbid conditions, if there are any, with 
which it is associated. 

Before giving the results of my observations, I will 
premise that, with the exception of elephantiasis and 
allied diseases, the selection of subjects for examina- 
tion was made without reference to their physical or 
social condition. Most were patients at the Chinese 
Hospital suffering from a variety of miscellaneous 
diseases, but many were relatives or friends in charge 

' * " China Customs Medical Eeports," 1877, No. xiv. 



72 



THE FILARIA SANGUINIS HOMINIS. 



of patients, and not themselves diseased ; others, 
again, were students at the hospital, or their relatives 
or acquaintances. 

The method of examination I employed was either 
to divide the droplet of blood, obtained by pricking 
the finger in the usual way, into six slides ; or, what 
was found to be more expeditious, to transfer the 
entire droplet to an ordinary slide, using half of 
another as cover glass. By the latter method the 
chance of the hsematozoon escaping from under the 
cover glass is diminished. 

1. The degree in luhich the general population of 
the Amoy district is affected with pilaria sanguinis 

HOMINIS.* 



Number examined. 


Filaria found in 


Percentage. 


Proportion, t 


670 


62 


9-25 


1 in 10-8 



* At the time (1876-77) these statistics were collected I had 
not discovered the law of filarial periodicity ; consequently, 
in order to get an approximate idea as to the prevalence of 
the filaria in the general population, I had to adopt some plan, 
such as I describe, of arriving at a fair estimate. I have not 
had leisure to go over the ground again, but it would be well 
if some one would undertake this work. Our knowledge of 
the phenomenon of filarial periodicity would simplify and 
shorten work very considerably. I may mention that subse- 
quently to the original pubHcation of these statistics they 
were extended so as to embrace over 1,000 individuals, but 
the extended series adds nothing of importance to what is 
here given. 

t Dr. J. L. Paterson has arrived at a very similar eonclu- 



PROPORTION OF POPULATION AFFECTED. 73 

A certain proportion of these cases came to hospital 
and were examined because they were affected with 
a filaria disease — elephantiasis. To arrive, therefore, 
at a correct idea of the degree of infection of the 
general population, these must not be included in the 
calculation. Slighter degrees of filaria disease, viz., 
varicose lymphatic glands and mild cases of lymph- 
scrotum, do not apply at the hospital on account of 
these affections, which, as a rule, are discovered only 
when searched for, the patients coming to be treated 
for some other complaint. I therefore include all 
cases of enlarged groin-glands, haK the cases of 
lymph-scrotum, but none of the cases of elephantiasis, 
as fairly representative of the general population. 

A correction must also be made for temporary 
absence of embryos in the blood in individuals who 
at another time might be found to possess them. As 
most of my cases were examined once only, it might 
so happen that just at the time the examination was 
made embryos were absent. To arrive at this 
correction I collected the results of a considerable 
number of examinations in persons all known to have 
filaria embryos in their blood at some time, and found 
from this the proportion of times in which embryos 
were absent and present. In an aggregate of 89 
such examinations they were found 55 times; not 
found, 34 times. That is to say, if a certain number 
of persons are examined once for filaria embryos, and 
these are found in 55 instances, we may infer that 
they are temporarily absent in a certain number 

sion as to the proportion of filaria-infested individuals to the 
general population in Bahia, Brazil. " Veterinarian," June, 
1879. 



74 



THE FILARIA SANGUINIS HOMINIS. 



of others, the proportion of present to temporarily 
absent being as 55 to 34. 



Number 

examined, 

less all the 

elephantiasis 

cases and half 

the lymph- 
scrotum cases. 


Number of 
cases in which 
embryos were 
found, less all 
the elephanti- 
asis and half 

the IjTnph- 
scrotum cases. 


Correction for 
temporary 
absence of 

embryos from 
the blood. 


Total of such 
oases examined 
affected with 
filaria sangui- 
nis hominis. 


Percentage. 


641 


51 


31-96 


82-96 


12-81 



From these figures we may conclude, that in Amoy 
and the surrounding districts, on an average about 
one person in every eight is affected with filaria san- 
guinis hominis ; and that in searching for embryos 
they will be found about once in every thirteen 
persons examined. 

2. The influence of age^ sex, and occupation in 
determining the ijresence of the 'parasite. 

Age. — By classifying the cases according to age, 
and in decennial periods, the progressive liability to 
filaria as age advances is well demonstrated in the 
following table : — 



T^ .1 • 1 Number 

Decennial period. „^ . „ -, 

^ examined.. 


Filaria Percentage 
jiiarid, to total cases 
found m^ ^f j,.j^^.^_ 


Proportion 
affected. 


10 to 20 ! 35 

20 „ 30 219 

30 ,,40 : 177 

40 „ 50 ; 133 

50 „ 60 70 

60 ,, 70 25 

Over 70 ^ 9 

Not ascertained . . 2 


2 

17 

16 

12 

8 

4 

3 


3-22 
27-42 
25-81 
19-35 
12-91 
6-45 
4-84 


1 in 17-5 
1 ,, 12-9 
1 ,, 11-1 
1 ,, 11-1 
1 „ 8-8 
1 „ 6-25 
1 „ 3 


Total 


670 


62 


100-00 





INFLUENCE OF AGE, SEX, AND OCCUPATION. 75 

Thus from youth to old age the liability to filaria 
gradually rises from 1 in 17*5 to 1 in 3. This is to 
be explained, partly at least, by the fact that 
the parent worm lives a long time — often a very 
long time — so that old age not only has its own 
liability to fresh infection, but possibly inherits the 
worms of youth and middle age. 

Sex. — Owing to the social prejudices of the 
Chinese, my opportunities of examining females 
have been few as compared with males — too few to 
warrant any conclusions as to special liability of a 
particular sex. 



Sex. 


Examined. 


Filaria found in. 


Proportion 
affected. 


Male 


620 
50 


57 
5 


1 in 10-88 
1 in 10 


Female 


Total 


670 


62 


1 in 10-8 



Occupation. — The following table gives the occu- 
pations of the different cases examined, and shows 
the number affected with filaria in each occupation. 
These are grouped according to social or physical 
circumstances, as fairly as the nature of the case 
admits, and proportion and percentage of filaria cases 
in each group given. 

I will attempt no explanation of the figures. 
They are too few to be of much value. They show, 
however, that no particular kind of occupation, with 
perhaps the exception of those of a seafaring cha- 
racter, secures exemption from filaria. 



o 



Ptural 



occupa 
tions . 



Trades . 



< 



( Cultivators . 
I Cowherd . . . 
( Milkman . . . 

Bakers 

Cobbler . . . 

Cooper 

Masons 

Builders .... 

Tailor 

Saltmaker . . 

Papermaker 

Coffinmakers 

Silversmiths 

Basketmakers 

Penmaker . . 

Carpenter . . 

Reader 

Blacksmiths 
"Washerman 

Shoemakers . . 

Sandahnaker 

Tanner 

Pedlars .... 

Barbers .... 

.Tinker 

'Students .... 

Schoolmasters 

Doctor 

Scholars .... 

Artist 

Gentleman . . 

Monk 

^Preachers . . 

Shopkeepers 

Cooks 

Shroff 

Clerks 

Gambler .... 
^Dom. servants 

Actor 

Chair coolies 

i Coolies 

i Millers 

I Soldiers . . . 
l^Policeman . 
( Boatmen . . . 
< Fishermen . 

( Sailors 

Occupation unknown. 
[Women 

Total . . I 



Literary 



Indoor 



Outdoor 



Sea 




ASSOCIATED MORBID CONDITIONS. 



77 



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78 



THE riLAEIA SANGUINIS HOMINIS. 



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ASSOCIATED MORBID CONDITIONS. 



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80 



THE FILARIA SANGUINIS HOMINIS. 



A glance at this table shows at once that ele- 
phantiasis and allied diseases are much more fre- 
quently associated with the parasite than is any other 
morbid condition. To bring this out more clearly I 
haye arranged the cases as follows : — 






^ X 



, u 

^ 1^ . 

o 2 " 

f-( g oj 

f-l g !» 






f-i oS 






CD Pi 
P-l O 



W 



"Elephantiasis of leg 

, , scrotum 

Lymj)li- scrotum . . 

Lymph.- scrotum and 

chyhiria 

Enlarged and vari- 
cose groin-giands 
Inflamed scrotum 

and fever 

Hydrocele ) 

Other diseases . . j 
No disease 



10 
15 
13 

2 

23 

2 
410 
195 



^ 63 ^ 



412 
195 



1 

4 
10 

2 

19 

2 

3 

11 

10 



>36 



58-25 



25-81 
16-18 



1 in 1-1 



1 in 16 

1 in 12 



670 



670 



62 



62 



58 



25-8 
16-2 



100 



In addition to the statement of the number of 
cases in which embryos were actually found, I haye 
appended the correction for temporary absence. The 
propriety of this is questionable, as many cases of 
elephantoid disease were examined several times 
before hsematozoa were found, and as the correction 
applies only to cases examined once, the addition for 
correction is too large. I would also add that every 
patient examined for filaria was not always examined 
for lymph-scrotum or enlarged glands ; and as these 
often exist in a slight degree without the patient being 
aware of it, several such cases have undoubtedly been 



ASSOCIATED MORBID COXDITIOXS. 81 

overlooked, and do not appear under the head of 
elephantoid disease. The scrotum and glands were 
carefully examined in every case in which filariaB 
were found. Making every allowance for these 
imperfections in the table, it still proves unquestion- 
ably the connection between elephantoid disease and 
filaria sanguinis hominis. 



CHAPTER V. 

CLINICAL EVIDENCE OF THE PARASITIC NATURE OF THE 
ELEPHANTOID DISEASES. 

I PROPOSE in this chapter to bring forward part of the 
clinical evidence on which the theory of the causation 
of elephantoid disease by the filaria, as described in 
the foregoing pages, is founded. The reader will 
have observed that a principal fact round which the 
theory has grown is the presence of filaria embryos in 
the disease I have called lymph-scrotum. This disease 
is found to be most intimately associated with chyluria 
on the one hand, and ordinary elephantiasis on the 
other ; so that the three diseases and their varieties 
may be considered but accidental modifications of the 
same pathological condition, and etiologically identical. 
Lymph-scrotum becomes therefore, at all events from 
a pathological point of view, a very important disease ; 
and a short description of its clinical features may be 
of use in aiding my readers to recognize and detect it 
in its milder and more complicated forms. A typical, 
well-marked case presents no difficulty in diagnosis. 

The characteristic feature of lymph-scrotum is the 
presence on the surface of the scrotum of vesicles and 
dilated lymphatics, which when they rupture spontane- 
ously, or are pricked, discharge coagulable lymph. 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 83 

Tlie number and size of these varices differ very- 
much. Perhaps there may be only one or two, per- 
haps there may be hundreds ; and they may be small 
as millet seeds, or large as the tip of the little finger. 
Similarly the quantity and physical characters of the 
fluid they discharge vary between very wide limits. 
In some cases only a drachm or two of fluid is 
discharged ; in others again five, ten, or fifty ounces 
will escape ; and in several instances the discharge 
has been so profuse, and has continued so long, that 
life has been endangered.* In certain cases the 
discharge is clear and straw-coloured, like hydrocele 
fluid ; in others again it is white, like milk ; in others 
salmon-coloured ; and in others again red, like blood ; 
and in the same case variations of colour occur from 
time to time, and even as the fluid continues dripping 
from the scrotum. It often happens that the lymph 
first escaping is milky white, but as it flows it becomes 
salmon-coloured, and then, finally, before it ceases to 
flow is red like blood. In every instance the fluid 
coagulates rapidly and spontaneously, the coagulum 
contracting rapidly so that after a day or two it may 
have nearly or entirely disappeared. The fluid then 
throws down a dark -red sediment, and its surface 
often becomes covered with a white, greasy-looking 
pellicle. If the sediment is examined with the 
microscope corpuscles like those of blood and lymph 
are found in abundance, and in five cases out of six 
a careful search is sure to be rewarded with the 
discovery of many active embryo filarise. 

As a rule in cases of lymph-scrotum, the inguinal 
and femoral glands are much enlarged. To the touch 

* Case XXY. p. 131 ; Case XXII. p. 123. 

G 2 



84 THE riLARIA SANOnXIS IIOMIXIS. 

they are soft and doughy, and are evidently varicose. 
If a hypodermic syringe, or holloA^' needle, is carefully 
and precisely introduced into one of them, large 
quantities of lymph exactly like that escaping from 
the vesicles on the surface of the scrotum can be 
procured.* In this also blood and lymph corpuscles 

* I would observe, for the information of those who wish 
to tap the lymphatic glands, that this trifling operation, as 
far as my experience goes, is unattended with danger. I 
have done it many times, often many times in the same gland, 
on the same j)atient. Within a few seconds of the withdrawal 
of the needle the neighbourhood of the glands swells suddenly, 
but by next day all disturbance subsides. Probably the 
puncture made by the needle in the varicose lymphatic ves- 
sels permits the escape of lymph into the connective tissue 
round the glands, hence the sudden swelling. Bleeding, or 
profuse escape of Ijonph, is easily controlled by pressure 
with the finger. When the glands are very varicose great 
abundance of lymph may be easily obtained, either by 
suction with the syringe, or by simply allowing the fluid to 
percolate through the needle into a glass, the syringe being 
unscrewed and laid aside altogether. In this way I have 
many times abstracted several ounces through one puncture 
at a sitting. When the glands are more solidified, as in 
advanced elephantiasis, there may frequently be some diffi- 
culty in procuring a specimen of lymph ; but if the needle is 
carefully and precisely introduced, and the glands then firmly 
squeezed between the fingers, the barrel of the needle on 
withdrawal is found, as a ride, to be full of lymph, and enough 
for a microscopic examination at all events can be blown out 
on a glass slide. Occasionally in such a case immediately 
following the withdrawal of the needle a droplet of clear 
lymph appears at the puncture, and if one is prepared with a 
slide may be secured before any sanguineous admixture takes 
place. When the l;}Tnph is very abundant large numbers of 
filariee may be found by collecting in a conical glass an ounce 
or two of the fluid, and waiting till the coagulum, which 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 85 

and, usually, filaria embryos abound. Pressure with 
the palm of the hand disperses the swellings, but on 
removal of the pressure the glands rapidly refill. 
Occasionally a case of lymph-scrotum is met with in 
Avhich the glands are not involved ; and, conversely, 
cases of varicose groin-glands are to be found in 
which the lymphatics of the scrotum are not 
dilated. 

If a lymph-scrotum is amputated, and before the 
operation wound is sewn up pressure is made on the 
dilated inguino-femoral glands, lymph, often in great 
abundance, can be made to regurgitate from dilated 
lymphatic vessels on the upper and femoral side of the 
exposed spermatic cords. 

A notable and characteristic feature of lymph- 
scrotum, as it is of ordinary elephantiasis, is the 
frequent occurrence of an eiysipelatoid inflammation 
of the affected parts, accompanied with a species of 
fever w hich Sir Jo sepJiJEayrer-Ms— v-ery-apt ly oall o d 
"elephantoid fever." This fever is ushered in with 
severe rigor, and is thus often called ague ; the hot 
stage is prolonged, and may be associated with de- 
lirium ; after a day or two it ends in diaphoresis, 
and not uncommonly^ anT escape of lymph from the 

presently forms, has dissolved, and a dark brown sediment of 
corpuscles collected at the bottom of the glass. This process 
of coagulation and solution usually takes from twenty -four to 
thirty-six hours. In the sediment hving filarise are always 
very abundant, and can be found readily. Of course, in em- 
ploying the needle of the hypodermic syringe in this way one 
must be sure of the diagnosis, and that there is no hernia ; 
regard also must be paid to the femoral artery and the large 
veins in the neighbourhood. With a little caution and skill 
no danger need be apprehended. 



I 



•86 THE riLARIA SANGUINIS HOMINIS. 

scrotum. There is no regularity iu the recurrence of 
the attacks of scrotal inflammation and fever.* Yery 
often abscess forms in the affected tissues, and until 
the pus escapes attacks of inflammation and fever 
are of frequent occurrence. Often it is an attack of 
scrotal inflammation and fever that first calls the 
patient's attention to his disease. These attacks are 
readily induced by exposure to coldT^alid wetjHby 
the friction of the thighs again str the scrotum in 
walking, by slight injury, and by alcoholic or other 
excesses. 

It is Tefy singular that a disease of so striking and 
peculiar a character has received so little attention 
from observers. Though many cases of lymphorrhagia 
from difierent parts of the body, especially from the 
legs and groins, have been published, and although 
in descriptions by various authors of cases of 
elephantiasis lymphous discharges from the parts 
affected have been alluded to, yet the first description 
of lymph-scrotum as a distinct pathological condition 
dates so recently as 1854. It was reported by Mr. 
Ardaseer Jamsetjee, in the " Transactions of the 

* Some writers maintain that the recurrence of the attacks 
of elephantoid fever bears a certain relation to the lunar 
cycle. I have often inquired about this from my patients, 
but never succeeded in establishing any proof of such a rela- 
tionship. The common causes of inflammation in other parts 
of the body are the common causes of elephantoid inflammation 
and fever ; and injuries of any sort, prolonged exercise, 
dependent position of the affected parts, attacks of malarial 
fever, and so forth, more readily cause inflammation in parts 
suffering aheady from lymphatic congestion or obstruction. 
There is nothing specific, however, in the fever or in the 
inflammation. 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 87 

Medical and Physical Society of Bombay " (yol. ii. 
new series, p. 341), as follows : — 

" Patient, a stout Parsee merchant, aged fifty; duration of 
the disease, seventeen and a half years ; preceded by an 
injury. There are vesicles of a minute size at the front and 
upper part of the scrotum, where the integument is rough 
and thick; from this a milky white fluid exudes, sometimes to 
a large amount ; this coagulates, and afterwards separates into 
two parts ; there are no (?) corpuscles in it. The discharge 
is irregular in its appearance, and subsequently the vesicles 
subside. The general health is good. The author supposes 
the occurrence of this discharge prevents increase of the 
hypertrophy of the scrotum which otherwise might take place." 

This is the case as condensed by Dr. Carter ; he 
adds that the character of the "milky" discharge 
was not detected. 

A second and a third case were published in the 
" Edinburgh Medical Journal " for January, 1860, 
under the title of "MilkyExudation from the Scrotum," 
as an extract from the " Eeport of the Missionary 
Hospital at Kumleefou in the Western Suburbs of 
Canton, for the year 1858-59," by Wong Fun, M.D. 
The description of the first of these is accurate and 
careful, and corresponds with many of the cases I 
have observed. 

The next and most important notices are by Dr. 
Vandyke Carter in the " Transactions of the Medical 
and Physical Society of Bombay," 1861 and 1862, and 
in the " Medico-Chirurgical Transactions " (vol. xlv. 
1862). In these publications will be found several 
well-marked cases very fully and carefully described, 
along with an elaborate discussion on the pathology 
of the disease, and its connection with the ordinary 
form of elephantiasis. 



88 THE FILARIA SANGUINIS HOMINIS. 

In his work on " Clinical Surgery in India," pub- 
lished in 1866, Sir Joseph Fayrer describes a case on 
which he operated — he calls it " neevoid elephantiasis." 
He again alludes to the disease in his " Clinical and 
Pathological Observations in India," published in 
1873, and also in the " Practitioner " for August, 
1875. 

A paper by Surgeon K. McLeod in the '' Indian 
Medical Gazette," for August, 1874, contains an inte- 
resting analysis of the literature of this subject, and 
describes a well-marked case observed by the writer 
himself. He calls the disease " varix lymphaticus," 
and remarks that it is not of unfrequent occurrence 
in India. 

These notices, along with brief allusions to it by 
Dr. Druitt in the ''Medical Times and Gazette," 
by Dr. Lewis in papers in the " Eeports of the Sani- 
tary Commissioners with the Government in India," 
by Eindfleisch, by Paget (" Lectui'es on Surgical 
Pathology," third edition), and numerous cases pub- 
lished by myself in the " China Customs Medical 
Eeports," included nearly all that had been wi'itten 
on this subject up to 1875. Since that date the 
literature of lymph-scrotum has considerably ex- 
panded, but it is still a little known disease. 

"What I have written, however, is sufficient to give 
the reader an idea of what lymph-scrotum is ; and 
will prepare him to understand better what is meant 
by this term in the narrative of the cases I will now 
give illustrating the connections between this disease, 
chyluria, elephantiasis, and the other filaria diseases. 
These cases bear out what I have akeady stated, that 
the various combinations and transitions of these 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 89 

diseases one into another prove the identity of their 
pathology. It is true that in fully-developed ele- 
phantiasis the filaria is by no means constantly 
present ; but if we can show that elephantiasis is 
only a modification of such diseases as lymph-scrotum 
and chyluria, in which the filaria is almost invariably 
found, we have strong reason, in addition to that 
derivable from other considerations, for deciding that 
true elephantiasis is also a filaria disease. 

I propose to arrange and narrate these cases in the 
following order : — 

1. Cases of chyluria in which the filaria sanguinis 
hominis was found. 

2. Cases of lymph-scrotum in which the filaria 
sanguinis hominis was found. 

3. Cases in which chyluria and lymph-scrotum were 
combined or alternated. 

4. Cases showing lymph-scrotum passing into 
elephantiasis scroti, the diseases co-existing. 

5. Case in which lymph-scrotum followed an ope- 
ration for elephantiasis scroti. 

6. Case of elephantiasis of the leg following opera- 
tion for lymph- scrotum. 

7. Cases of lymph-scrotum and elephantiasis of the 
leg combined. 

8. Case of lymphorrhagia in an elephantoid leg, 
combined with varicose groin-glands and filarise ; 
chyluria subsequently developed. 

1. Cases of chyluria in tvhich the filaria sanguinis 
HOMINIS tvas found. 

The number of times in which the parasite has 
been found in cases of chyluria is now so great, that 
the almost invariable association of the parasite with 



90 THE FILARIA SANGUINIS HOMINIS. 

this disease is considered established. It is, therefore, 
unnecessary for me to narrate any cases specially 
under this head. It will suffice if I refer the reader 
to those detailed by Lewis (" Eeports of the Sanitary 
Commissioner with the Government in India," No. 6, 
1869); to the remarkable case narrated by Dr. 
Stephen Mackenzie in the " Transactions of the Patho- 
logical Society " for 1882, vol. xxxiii. ; to the cases of 
Wucherer in which the parasite was first found; 
and to several given by myself in this volume, and 
in different numbers of the '-' China Customs Medical 
Eeports." It may be safely affirmed, that in five 
cases out of six of chyluria in which the parasite has 
been carefully and properly searched for it has been 
found, both in blood and urine. But to be found, 
the parasite must be searched for at the proper times 
and in the proper way. It is useless to look for it in 
blood drawn during the day ; it must be drawn at night, 
and best between the hours of nine p.m. and three a.m. 
If looked for betwixt these hours, and in these cases, 
it will almost invariably be found. In the urine it is 
as abundant during the day as during the night ; but 
it will not suffice to examine a drop only of the urine. 
A considerable quantity should be collected, well 
stirred so as to break up all clots, and then stood 
for several hours, during which the filarise it may 
contain will subside to the bottom of the vessel. 
The sediment ought then to be removed by a pipette, 
and carefully searched with the microscope. In this 
way the parasite will nearly certainly be found.* 

* Many fail to find the embryos because they use glasses 
of too high a magnifying power. A half-inch or three- 
quarters object glass is quite high enough for searching 



TAKASITIC NATURE OF ELEPHxiNTOID DISEASES. 91 

The occasional absence of the embryo in cases 
of tropical chyluria is readily accounted for by the 
death of the parent worm, an event that does some- 
times happen. But, although the original cause of 
the disease has disappeared, it does not follow that the 
damaged lymphatics recover. An acquired varix of 
any sort does not tend towards recovery. Conse- 
quently chyluria may not always be coincident with 
the presence of the worm in blood or urine, and yet 
the original cause of the disease was the worm. 

2. Cases of lymph-scrotum in which the filaria 
SANGUINIS HOMiNis was found. 

The same remarks apply to lymph-scrotum that 
apply to chyluria. In five cases out of six the 
filaria is present in blood and lymph, and, by observ- 
ing the precautions as to time and method of search, 
can readily be found. Many cases of filarious lymph- 
scrotum are now on record, so that it is hardly 
necessary for me to do more than give a brief sketch 
here of one or two by way of illustration. 

I should premise that the cases I record were seen 
and examined by myself at the Chinese Hospital 
in Amoy. In some instances the patients were only 
seen once ; in others, again, they remained a con- 
siderable time under observation, so that the record 
is not in every case equally complete. 

Case V. Lymph-scrotum ; filaria embryos in blood and lymph. 
— Mng, male, aged thirty-seven, a farmer from Tchoantchiu, 
Lamtia ; on a visit to Amoy. In his village (population over 

purposes. A large field by using these low powers can be 
examined quickly and thoroughly. It is perfectly useless to 
attempt finding the embryos with an eighth, or a quarter 
even. 



92 THE FILARIA SANGUINIS HOMINIS. 

2,000) he knows of three other oases like his own, he says, but 
does not know of any cases of elephantiasis. The water he 
drinks comes from a stream ; it is stored in a jar which is 
filled up every day, but emptied and cleaned only every four 
or five days. Sometimes he drinks water from the paddy 
fields. 

When young (about fourteen years of age) had fever, 
and since then, whenever his work lies in the wet rice fields, 
has frequent attacks of fever ; of late, for the last three or 
four years, the attacks have been very frequent. The attack 
sometimes comes on while he is in the field, sometimes later 
when he is in bed. It begins with a severe rigor, lasting for 
about two hours ; then he has high fever for twelve hours ; 
and then the attack terminates in a short and mild diapho- 
resis. The scrotum and inguino-f emoral glands become swollen 
and very painful during the hot stage of the fever, and it is 
not until after three days that he can leave his bed, the 
scrotum beginning about that time to discharge. He has 
been subject to these discharges for two years only. The 
glands have been enlarged for seven years, but he has been 
subject to fever for over twenty years. The fever has been 
of the same (elephantoid) character from the beginning — 
never of the tertian or quartan ague type. He has never 
had chyluria. 

His lymph-scrotum and enlarged inguino-femoral glands 
are typically developed. He has no elephantiasis. He is 
thin, but looks in good health. 

April 27th, 1880. — I drew off from the inguinal glands 
with a hollow needle specimens of lymph as follows : — 

From right side 2^ ounces pale salmon-colom-ed and 
coagidating, at 6.30 a.m. This specimen I marked " 1." 

From left side 2 ounces dark salmon-coloured and 
coagulating, at seven a.m. ; marked " 2." 

From the right side, at mid-day If ounces salmon-coloured 
and coagulating ; marked " 3." 

From the left side at the same time 2 drachms dark 
salmon-coloured and coagulating ; marked " 4." 

From the right side at six p.m. li- ounces pale salmon- 
colom'ed and coagulating ; marked "5." 



PAKASTTIC XATT'PE OF ELEriTAXTOlD DISEASES. \)6 

Blood draAvn from tlie finger at seven a.m. contained in 
one slide measuring 1^-in. x 1-in, five filarias ; a similar 
quantity drawn at mid - day contained no filarise ; at 
5.30 p.m. no filarise ; at seven p.m. one large drop contained 
eight filarise. 

The lymph drawn off from the glands was allowed to 
stand that the coagulum might have time to contract or 
disappear; on April 28th — next day — various glasses were 
examined. 

Six a.m. — No. 1. Still contains a slight coaguhmi ; filarige 
abundant. No. 2. Dark red, fibrous, semi-coagulated deposit ; 
four filarise in one slide. Nos. 3, 4, 5, still contain large 
coagula. 

Six p.m. — No. 5. Still coagulum ; no filarise found in 
two large slides. No. 4. Two dead filaria3 in one slide. 
No. 3. No filarise in one slide examined. No. 1. Two slides 
examined ; one filaria. No. 2. No filariae in one slide. 

April 29th, six a.m. — No. 1. One slide ; no filarise. No, 2. 
One slide ; four living active filarise. No. 4. No filarise in 
one slide. No. 3. One living filaria in one slide. No. 5. 
No filarise in one slide. 

April 30th. — Drew off from right inguinal glands about 
two ounces of clear, straw-coloured, coagulating lymph about 
11.30 a.m. After the coagulum had disappeared and the glass 
containing the lymph had stood for some hours, large num- 
bers of filarise were found in the sediment. 

The next case is an example of ordinary lymph- 
scrotum. I introduce it here partly as being an 
example of the presence of the filaria in the blood 
and lymph, and partly as it records an experiment on 
the effect of chloroform narcosis on filarial periodicity. 
In this instance the chloroform had no effect in throw- 
ing the embryos into the general circulation at a time 
when they are normally absent ; but in the second 
instance of a similar experiment, to be presently nar- 
rated, it apparently did have some effect (see p. 104). 



94 THE FILARIA SANGUINIS HOMINIS. 

Case VI. Lymph-scrotum ; removal under chloroform ; 
periodicity of filaria embryos not affected by the chloroform. 
— Lo, male, aged thirty-six ; a merchant in Amoy. This 
was a case of ordinary lymph-scrotum, with filarise both in 
blood and lymph. 

' August 11th, 1880. — The scrotum was removed under 
chloroform. The operation lasted from 12.30 to 1 p.m. 
During its progress blood was drawn from a finger three 
times and examined with the microscope, but no filarise were 
found ; and immediately prior to the operation, also, it was 
ascertained that they were absent from the blood. Blood was 
again examined at three p.m., when the effects of the 
chloroform had passed off, but embryos were still absent. 
Filaria embryos in very small numbers were found in the 
juices expressed by the contracting scrotum after removal ; 
but though carefully searched for during two hours no parent 
worm was found in the tumour. The blood was frequently 
examined during the subsequent progress of the case, viz., 
on August 25th, September 10th, 15th, 24th, and October 
10th, and was on each occasion found to contain filarise; of 
course the examinations were not made during the day. 

Case YII. Excessive development of lymph-scrotum and 
varicose inguinal glands; filarice, in scrotal lymph (see plate IV.). 
— Hock Seng, male, aged thirty-two ; born in Tchoantchiu, 
but been in Amoy, where he works as a tailor, for the last 
sixteen years. He was brought up in very poor circum- 
stances, and has been delicate since childhood, being subject 
to attacks of quartan ague. 

I saw him on August 9th, 1881. He told me his scrotal 
disease began about three years before with fever and local 
inflammation, and pain over the bladder. Since then the 
groin-glands and scrotal lymphatics have become varicose. 
Lymphous discharge from the scrotum occurs every few days ; 
sometimes only once a fortnight. When once started it con- 
tinues for two or three days. On first appearing the discharge 
resembles rice-water, but as the flow continues it gradually 
becomes sanguineous. Fever is now very irregular, and is 
always accompanied by much pain in the groins, scrotum, and 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 95 

belly. He told me that a long transverse scar in the left 
groin over Poupart's ligament was the result of a large abscess 
he had five or six years ago. There is a small reducible swell- 
ing which may, or may not, be a hernia on the left side ; he 
says its appearance was coincident with the development of 
the scrotal disease. The groin-glands on both sides, but 
especially the left, are very large and soft. The scrotum is 
dusky, thickened, large, and pendulous ; its lower part is like 
a soft elephantiasis, but on both sides, and also behind and in 
front, the lymphatics are exceedingly varicose ; in front and 
behind they are like bunches of purple grapes, on the sides 
they are smaller — like currants. A small incision into one of 
the varices gave vent to a large stream of dark brown, blood- 
like lymph. The stream was_ large and strong, as if from a 
big vein. Fearing to injure him by drawing off too much, to 
stop the flow I had to take up the wound with a forceps and 
include it in a ligature. He told me the scrotum had dis- 
charged only four days before. He distinctly states that, 
as a rule, under ordinary circumstances of spontaneous 
rupture, the discharge at first is white, like pus, and then as it 
runs becomes gradually dark red, resembling what I drew off. 
I found three filarise in a small drop of lymph drawn at 
seven p.m. 

Many cases similar to these, as regards the presence 
of embryo filarise in blood and lymph, I have recorded 
in the " Customs Gazette." It is unnecessary, therefore, 
to multiply examples here. 

3. Cases in which chyluria and lymph-scrotum were 
comhined or alternated. 

The first example recorded of this combination we 
owe to Dr. Vandyke Carter ; but as at the time the 
record was made the filaria had not been discovered, 
no mention of its presence was made. Probably had 
it been looked for in the proper way it would have 
been found. Describing the case. Dr. Carter says : — 

" Four months since, the scrotum began to enlarge ; native 



96 THE FILARIA SAXGUIXIS HOMINIS. 

applications were made, and it was only after a time that the 
peculiar corrugation of the skin appeared. The milky dis- 
charge regularly occurs spontaneously, and it intermits; at 
present it has been going on for two days, and he reckons 
to have lost about one pound of fluid daily. It does not 
issue from any one spot, but from several ; it may be accord- 
ing to, the number and position of the tubercles that have 
burst. When it ceases, and sometimes also when the dis- 
charge is going on, the urine becomes chylous, and fre- 
quently coagulates. Such is his own account. Health 
indifferent. No appetite. He was afterwards admitted into 
hospital, and I found that the tumefaction of the inguinal 
glands seemed to alternate with the appearance of chyle in 
the m'ine. This circumstance was sufficiently established. 
The parts became tumefied a short time (two or three hours) 
after a full meal, and then again subsided. There did not 
appear to be any regularity in the appearance or disappear- 
ance of chyle in the urine." 

Lewis records a case in which the scrotum became 
the subject of elephantoid enlargement (probably 
lymph-scrotum) two years after the appearance of a 
filarious chyluria. Towards the end of 1873, the 
same observer had the opportunity of examining a 
case in which chyluria was combined with an 
elephantoid state of the scrotum. Filariae were 
found. 

" The patient was a Jew, and was suffering from acute 
pain produced by an inflamed condition of a moderately 
large scrotal tumour. This tumoiu' had been coming on for 
many years, and increased and diminished in bulk at 
iiTegular intervals. It was studded with tubercular pro- 
minences, soft and yielding to the touch, and when a trocar 
was introduced several ounces of sanguineous fluid were 

withdrawn The chylmia had only been observed 

about a fortnight previously." 

He also mentions a third case which supplied 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 97 

specimens of the filaria, and in which an elephantoicl 
condition of the scrotnm and foot co -existed with 
chyluria.* 

The following are examples of the combination 
occurring in my own practice : — 

Case VIII. History of elephantoid fever ; chyluria and 
lymph-scrotum co-existing ; elephantiasis of the scrotum. — 
KuGHOK, aged twenty-five ; a labourer from Chin Chiu, in 
very poor circumstances. When sixteen years old he had what 
he calls fever and ague, which lasted for four days, and during 
this time his scrotum got inflamed and swollen. "When the 
fever was past the inflammation and swelling subsided. From 
that time till he was seen at the hospital he had fever attacks 
twenty or thirty times a year, his inguinal glands and 
scrotum enlarging, the latter gradually becoming covered 
with small vesicles which on bursting would discharge about 
twelve ounces of milky fluid. On admission he was seen to 
be strong and well-built, and, with the exception of sHght 
ansemia, had the appearance of a man in the enjoyment of 
good health. He stated that he had been passing " white " 
urine for some weeks past. On examining the scrotum it 
was found to be much enlarged, the skin thick and coarse, 
the penis almost completely buried, presenting in fact the 
usual appearances of an elephantiased scrotum of about two' 
poimds weight, with, in addition, numerous transparent 
vesicles covering the surface. On puncturing one of the 
vesicles about ten ounces of fluid were discharged, the first 
portion being clear, like water, then gradually becoming like 
milk, and the last few ounces like a mixture of blood and 
milk. On the following day his urine, which was chylous 
before, became natural. The scrotum was amputated ; 
it weighed two pounds, and had the usual appearance of 

* In this connection the reader is referred to a re- 
markable case related by Roberts in his " Urinary and Renal 
Diseases," in which a varicose condition of the lymphatics 
of the abdominal integument was associated with chyluria. 

H 



98 THE riLAEIA SANGUINIS HOMINIS. 

elephantiasis, a strong outer rind enclosing a blubbery-like 
mass. The filaria was not searched for. 

Case IX. Elephantoid fever ; lymph-scrotum and intermit- 
ting chyluria. — Tanhok, aged twenty-six ; a labourer 
from Chiupo, in poor circumstances, and of a phthisical 
family. When ten years old he had fever and ague, 
which lasted for thirty days. When twenty - three had 
a second attack of fever, this time accompanied by 
pain and swelling of the inguinal glands and scrotum. 
After about three weeks, and when the fever had sub- 
sided, the scrotum became covered with numerous small 
vesicles, which caused much annoyance by constant itching. 
After ten months a vesicle burst, discharging a considerable 
quantity of white fluid. From that time, sometimes once in 
five days, sometimes once in ten or twenty days, a vesicle 
would burst discharging ten to fifteen ounces of fluid. On 
coming to hospital he was suffering much from anaemia and 
debility, but his appetite and digestion were unusually good. 
A vesicle was cut open, and fluid, at first white and after- 
wards of a reddish-white colour. Continued to be discharged 
until the afternoon of the following day. The fluid measured 
flfty-four ounces, not including some few ounces which were 
unavoidably lost. Four days afterwards he had a second 
discharge of fluid — twelve ounces — from the same vesicle as 
we had opened. A week afterwards the patient called atten- 
tion to his urine, which, he said, he had been unable to pass 
for eight or ten hours. The urine was in large quantity, of a 
reddish- white colour, and coagulated rapidly. He complained 
of pain in the passage. After a few days the urine again 
became natural. The diseased part of the scrotum was 
removed by the knife, and the parts healed up rapidly, but 
on the day following the operation the urine became white, 
like milk. After three weeks he returned home. Two 
months afterwards he again came to hospital. He stated 
that his urine was still white, although at times it was almost 
natural. A small patch — about an inch square — of the skin 
of the scrotum was seen to be covered with vesicles. It was 
excised. Wlule he remained in hospital he continued to pass 



PARASITIC NATUEE OP ELEPHANTOID DISEASES. 99 

from seventy to eighty ounces of chylous urine daily, of a 
specific gravity of about 1015. Though the filaria was 
searched for in this case it was not found, probably because 
at that time the habits of the parasite were not known, and 
the proper methods were not employed. 

Case X. Hcematozoa ; chyluria and lymph-scrotum. — Tho, 
aged forty, a farmer from Tchiupo, Pholam-Kio. Says 
there is no elephantiasis or leprosy among his neighbours. 
Till thirty-five or thirty-six years of age he was a strong, 
healthy man, but about that time had, from what I can 
make out from his description, prolapsus ani. When 
eighteen years old had an abscess in his scrotum. Elephantoid 
fever began about his thirty-sixth year ; the attacks con- 
sisted of rigors, pyrexia, and sweating, the whole paroxysm 
lasting about six hours. Grlands and scrotum have been 
affected since this fever first showed itself; their periodical 
swelling and inflammation appearing, from his description, 
to be secondary to the attacks of fever. These attacks occur 
irregularly from once to several times a month ; the last 
attack, only four days prior to his admission to hospital. He 
knows of no cause for his complaint. 

His is a fine specimen of Ijnnph-scrotum ; it has never 
discharged spontaneously, but on pricking one of the many 
vesicles on its surface two to three ounces of rapidly-coagu- 
lating straw-coloured lymph exudes. There is no hardening, 
and but slight enlargement of the scrotum, which is soft, 
silky, and pendulous. The inguinal and femoral glands of 
the left side are very much enlarged and varicose ; those of 
the right side are also enlarged, but to a less extent, and are 
harder to the touch. 

Three months ago he first noticed blood and clots in his 
urine ; at the time he had a slight attack of the usual fever. 
Since that time his urine has never been quite free from blood 
and clots, the amount of these diminishing or increasing 
according to the amount of work he does. Since the estab- 
lishment of the chyluria fever attacks are more frequent, and 
he has become very anaemic and debilitated ; so much so that 
he cannot keep on his legs for any length of time, but is 
compelled to lie or sit down. 

h2 



100 THE FILARIA SANGUINIS HOMINIS. 

July llth, 1877, lie came to hospital ; on tlie 14tli I note 
that his blood and chylous urine had been frequently 
examined (dimng the day), but in neither had filarise been 
found. He was put on large doses of gallic acid and tonic 
doses of quinine. On July 15th I note that I examined two 
specimens of his urine. One of them, passed during the 
previous night, had been standing in a conical glass for 
about twelve hours, and had separated into three well- 
marked zones ; the uppermost, and most bulky, was of a 
pale salmon colour ; the middle was of a considerably redder 
tinge than the former ; and the lowest was of a dark red, 
like blood, and formed a mere sediment at the bottom of the 
vessel. I examined many slides of this sediment, and, after 
a prolonged search, found one dead heematozoon in it. The 
other specimen of urine, passed only two hours before 
examination, was a dirty red colour throughout, with several 
very firm clots floating in it ; specific gravity, 1012. No 
filarise were found in it. Blood, lymph, and oil corpuscles 
abounded in both specimens of urine. 

July 16th. — An assistant found two filarise in blood to-day. 

July 19th. — He found one filaria in blood last night, and 
this morning I confirmed his observation by finding two more. 

July 22nd. — He returned home, having derived no benefit 
from the very large doses of gallic acid he had been taking. 

Case XI. Hcematozoa ; chyluria and lymph-scrotum. — 
Kau, aged seventy-two ; a pedlar living in Amoy. He 
says that there is no elephantiasis in his family ; that about 
thirty years ago he visited Formosa and Tientsin, but with 
this exception has always resided in and about Amoy. 
Thirty or forty years ago had an aguish attack of very 
short duration, and, as far as his memory serves him, had 
abscess in the scrotum about the same time. It was not, 
however, until a few years ago that he became liable to 
attacks of swelling of the groin-glands ; this recurred every 
three or fom^ months. His scrotum has been swollen, a little 
over two years only. Occasionally .he has rigor and fever, 
and then the scrotum itches excessively, inflames, and becomes 
covered with minute white vesicles ; these burst and discharge 



PAEASITIC NATUEE OF ELEPHANTOID DISEASES. 101 

a large quantity of fluid. When this happens he passes 
urine ; white like milk, for a few clays ; when the discharge 
from the scrotum ceases, that of chyle in the urine also dis- 
appears. This chyluria has occurred many times during the 
last two or three years. He is much troubled with rheumatism. 

The scrotum is large, pendulous, and vesiculated, and the 
glands on both sides are swollen and varicose. 

Filarise were found in great abundance in his blood. 
Doubtless they were present also in scrotal lymph and 
chylous urine, but I have no record of their having been 
searched for. 

4. Cases showing lymph-scrotum passing into elephan- 
tiasis scroti^ the diseases co-existing. 

Wlien we inquire into the early history of cases 
of ordinary elephantiasis of the scrotum, in many 
instances we get a description of lymph-scrotum ; and 
are often told that when the discharge characteristic 
of this affection ceased to recur, the scrotum began 
to enlarge. I have operated on over a hundred cases 
of elephantiasis of the scrotum, large and small, and 
the early history of many of these was that of 
lymph-scrotum. Dr. Allan Webb, in a paper on 
"Elephantiasis Orientalis " in the "Indian Annals 
of Medical Science" (I^o 4, April, 1855 j, details such 
a case. His patient gave the usual history of fever 
and inflammation. 

"After each attack of fever, dming a period of four years, 
the scrotum would transude a quantity of white, ropy- 
looking matter, which very much reduced its bulk. . . . But 
about ten months ago this suddenly ceased, and the tumour 
rapidly doubled in size. The manner of transudation, he 
says, is that during the paroxysm of the fever minute 
vesicles, about the size of a pin's head, appear ; they are 
scattered all over the surface of the tumefied scrotum ; they 
become very prominent and distended with serum (?) after the 
fever subsides, and break rapidly and discharge their contents." 



102 THE FILAHIA SANGUINIS HOMINIS. 

When these periodical escapes of -fluid ceased to 
recur, then the tumour assumed gradually the bulk 
and appearance of ordinary elephantiasis, I have 
recorded several examples of scrota in the transition 
state, and possess notes of many more. It will 
suffice if I give three or four by way of illustration. 

Case XII. Hcematozoa ; elephantiasis and lymph-scrotum 
combined. — Ang Khi, aged fifty-eight; a cake baker from 
ChangcMu, in comfortable cu-cumstances. He states that 
when twenty-eight years of age, in the spring of the 
year he had an attack of what he calls ague, accom- 
panied by inflammation of the scrotum. The fever lasted 
for only one day, but it was two months before the 
scrotum returned to its original size ; before doing so it 
desquamated. Since that time he has had attacks of 
fever every year from four to eight times, each attack 
being accompanied by inflammation of the scrotum. 
Two years ago the scrotum did not, as formerly, recover 
after the fever, but remained swollen, and has grown 
steadily ever since. Formerly he was stout and strong, 
but for the last ten years has lost flesh. He has never had 
chyluria. His scrotum presents the usual appearance of 
elephantiasis. I suppose it to weigh about eight pounds. 
On its ujider surface there is a solitary vesicle, about 
the size of a split pea, and near this a bunch of dilated 
lymphatics ; pricking any of these gives vent to a drachm 
or two of coagulating milky lymph. His blood, on exami- 
nation, was found to contain many filarise. 

Case XIII. Hcematozoa; lymph-scrotum and elephan- 
tiasis scroti. — PoE, aged forty-five ; a shopkeeper from 
Tchoanchiu, Tchin Kang. No leprosy or elephantiasis 
in his family, but a neighbour has elephantiasis of a leg. 
He states that at seventeen he had a tertian ague, lasting 
for two months. At forty-two had his fii'st attack of 
the fever, which for the last three years has never left 
him for more than a few days at a time. Describes the 
fever as commencing with a feeling as if produced by 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 103 

retraction of the spermatic cords, giving rise to so niucli 
pain that he has to leave off work at once ; this is 
immediately followed by rigors, fever, and sweating, the 
whole attack lasting about six hours. He says that his 
disease commenced by an attack of chills coming on in the 
middle of a very long and wet journey ; when he got home 
he had fever, and next day he discovered that his groin- 
glands were enlarged, and his scrotum oedematous ; in a 
month's time vesicles had formed on the sui'face of the 
scrotum. With successive attacks of fever the scrotum 
inflamed, became permanently enlarged, and at times dis- 
charged a white lymph in great abundance, four or five 
ounces. His fever, he says, never comes on dming the 
night. 

A mass of elephantiasis, weighing about two and a half 
pounds, involving both penis and scrotum, was removed, 
and the penis and testes were left bare to cicatrize. This 
process took about four months to accomplish ; during the 
whole of that time he had no recurrence of the fever, which, 
prior to the operation, attacked him every few days. The 
glands in the left groin appear to be quite healthy ; not so 
those on the right side, where a large tumour is formed by 
the enlargement of a bunch of them over the saphenous 
opening, and another cluster over Poupart's ligament. To 
the touch they are firm, and not varicose. Hsematozoa 
were found in his blood. 

Case XIY. Elephantiasis of scrotum and lymph-scrotum 
comhined ; filar ia embryos in lymph from raricose groin- 
glands, but not in the blood. — Heng, aged thirty-eight; 
a chair coolie from Hooieoah. He says there is no case 
of elephantiasis in his family or neighbom-hoocl, as far 
as he knows. Has had an enlarged scrotum for three 
or four years, which he attributes to his having slept on 
one occasion on the hillside in the rain. Has six or seven 
attacks of elephantoid fever every year, accompanied by the 
usual and characteristic inflammation of the scrotum. Last 
year there was a discharge from the scrotum, but there had 
been no recurrence of the discharge since then. When 
admitted to hospital the scrotimi had rather the appearance of 



104 THE riLARIA SANGUINIS HOMINIS. 

elephantiasis, although it felt softer than is usual in a well- 
marked case of this disease. No distinct dilated lymphatic was 
visible on the scrotum, but the inguinal and femoral glands 
on both sides were much enlarged, some of these being 
varicose, others consolidated. He said he never had 
chyluria. 

I thrust the needle of a subcutaneous syringe into one of the 
varicose inguinal glands, and in this way procured a small 
quantity of milky lymph. In this I found a languid fllaria 
embryo. The following morning I examined six large 
slides of this man's blood, equal to about six droplets, but 
could find no filarise in it. The subcutaneous syringe was 
again used to extract lymph from the groin-glands. In the 
clear lymph thus obtained fom^ filarise were found in six slides, 
one slide containing two. The embryos were very languid in 
their movements, one at least being shrivelled, the lash at its 
head standing out very distinctly, even when viewed with a low 
power. Besides the unquestionable filaria embryos, numbers 
of threads, about -p^-ui- in length, were found in the lymph, 
their appearance suggesting the idea that they were the 
collapsed sheath of the embryo, the body of which had 
disappeared by absorption or disintegration. 

This man's scrotum was amputated. It had the ap- 
pearances usually met with in ordinary elephantiasis, and 
weighed about two and a half pounds. Though carefully 
dissected no mature filaria was found. After the operation 
the swelling of the glands subsided, and the case did well. 
Though examined daily for nearly a month no embryo was 
ever found in his blood. 

Case XY. Lymjjh-scrohim passing into elephantiasis; 
hcematozoa in blood and lymph from scrotum ; amputation. — 
PoA, aged forty-one ; a farmer from Tchin Kang, 
Lamoa. At eighteen or nineteen had shivering and fever, 
with bleeding from the nose and general dropsy. This 
dropsy, he says, lasted for about a month, and then every- 
where disappeared but in the scrotum, which remained red 
and thickened. Often since that time he has had attacks of 
elephantoid fever and, frequently, discharges from his scrotum. 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 105 

There is no positive history of chyluria, but he said that 
before the first attack of scrotal swelling he passed white 
urine in small quantities. 

The scrotum is very large for an ordinary lymph-scrotum ; 
it is greater than a large pumelo, and is dense. Inguinal 
and femoral glands on both sides prominent and varicose. 
There was a copious discharge of milky-red coagulating 
lymph from a small wound on the penis, accidentally made 
whilst clipping hair prior to operation. 

October 8th, 1880. — A slide of blood, l-|--in. x 1-in., 
drawn at 6.15 p.m., contained eleven embryos. About an 
ounce of lymph collected and set aside. Lymph had been 
running all day, and that set aside for examination was 
collected about six p.m. 

October 9th, six p.m. — Many dead embryos found in the 
dark red lymph-sediment. 

October 10th. — Scrotum removed under chloroform at 
noon to-day. The operation and narcosis lasted about twenty 
minutes. The scrotum and foreskin weighed four pounds 
and a half. Specimens of blood drawn at the time of the 
operation were examined for filarise, with this result : — 

Blood from finger before operation ... ... no filarise. 

,, „ ,, alter ,, ... ... 4 ,, 

„ ,, spouting artery during operation ... 6 „ 

„ „ incision in penis ,, „ ... 1 „ 

At six p.m. a specimen from the finger contained twenty- 
seven filarise. 

October 15th, slide of blood at 5.30 p.m. ... 1 filaria 

„ 16th „ „ 5.30 a.m. ... 5 filarise 

„ 22nd „ „ 5 p.m. ... 8 „ 

November 3rd ,, „ 5 p.m. ... 7 ,, 

The case did well. 

The chloroform in this case, unlike what happened 
in one already narrated, apparently had some effect 
in throwing the embryo filarise into the general circula- 
tion at a time when they are normally absent. 



106 THE PILARIA SANGUINIS HOMINIS. 

Case XYI. Lympho-ekphantoid scrotum ; filarice in lymph 
from scrotum and in the blood. — Thi en iet, aged forty- 
eiglit ; a farmer from Toliiiipo. None of his relatives 
have elephantiasis, but the disease is very common in his 
neighbourhood. He says that he often drinks cold water 
in the warm weather ; it comes from a well, hut is 
usually stored in a jar for two or tliree days; there are 
many mosquitos in his house, and they can easily get 
access to his water- jar. Until his scrotal disease began 
had no disease but ague. His scrotum has been affected for 
over ten years. It began with inflammation and elephantoid 
fever. The first attack kept him in bed for over a month, 
and until he was relieved by a copious yellow, serous-looking 
discharge from the surface of the scrotum. Since that time 
has had many such attacks irregularly once or twice a 
month, but the discharge is independent now of the fever, 
and occurs very frequently. Eough trousers by scratching 
are sufiicient to induce it, and it will run for an hour at a 
time. He has never had chyluria. 

The scrotum is as large as his head. It is rough, thick 
and in a state of genuine elephantiasis, with a dense rind 
apparently about an inch in thickness. The penis is quite 
buried in the mass. In fact, but for three or four large 
vesicles the size of swan shot, and which on being pricked 
discharge a sanguineous lymph, it is an ordinary example 
of elephantiasis. The groin-glands are slightly, but only 
slightly, enlarged, and are not at all varicose. Two ounces 
of a reddish sanguinolent lymph distiUed guttatini from a 
vesicle in about a quarter of an hour. On the surface of 
the scrotum are several small tumours resembling in size 
and shape the vesicles, only differing from them in being 
solid ; evidently at one time they had been vesicles, but had 
solidified ; others again were semi-fluctuating, apparently in 
a transition state. 

November 28th, 1880. — In scrotal lymph, drawn at 
6.30 p.m., I found many filarise. Blood drawn at the 
same time contained eight to a slide l|-in. x 1-in. At 
8.30 p.m. the lymph continuing to run had become clearer 
and was free from red tinge. Three drops of it were 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 107 

searched and only yielded two filarise. The blood now con- 
tained twenty-three to the slide. 

November 29th. — Scrotum amputated. It weighed four 
and a half pounds. Several filarise were found in lymph 
from a vesicle, but at the same hour (mid-day) none could be 
found in the blood. 

January 2nd, 1881. — The case has done well. Every 
night till date the blood has been examined, about nine p.m., 
and on every occasion was found to contain filarise. 

I could give many more examples of lymph- 
scrotum passing into elephantiasis. It is quite a 
common thing where filaria disease is endemic ; but 
the opposite or converse phenomenon of elephantiasis 
terminating in lymph-scrotum is very rare indeed. I 
haye only met with it once ; the following are some 
notes of the case. 

5. Case in which lymph-scrotum followed operation 
for elephantiasis scroti. 

Case XVII. — Ong an, aged thhty-five ; a field labourer 
from Tchoantchiu. Came to hospital in 1872 to be operated 
on for elephantiasis of the scrotum. His disease began about 
five years before. He gave the usual history of elephantoid 
fever, inflammation of the scrotmn, and gradual enlargement 
of the tumour. He was operated on, and a tumour weighing 
ten pounds was removed. In 1879 he came to see me — that 
is seven or eight years after the operation. He said that 
after leaving the hospital he went home with his wound quite 
healed, and returned to his fields working hard as an 
ordinary labourer. For five years his scrotum gave him no 
trouble whatever, but kept sound and free from inflammation 
or- swelling of any sort ; and in other respects he enjoyed 
good health. About this time, however, he had a mild 
attack of elephantoid fever ; and since then, especially after 
unusual exertion, has had many similar attacks — about five 
or six, he says, every year. The fever is not accompanied by 
distinct inflammation of the scrotum, but this swells and 



108 THE PILARIA SANGUINIS HOMINIS. 

feels painfully constricted. Sometimes, about three times a 
year, but only for the last three years, he has a discharge of 
milky coagulating fluid from the scrotum. When the dis- 
charge begins to flow it is clear, like water, but after running 
for five or six hours it gradually becomes opaque and milky, 
and continuing for about six hours longer it gradually ceases 
to flow. He is quite positive in his statement that he never 
had any sort of lymphorrhagia before the operation, and 
neither before nor since has he had chyluria. 

I carefully inspected his genitals and found them, as far as 
the operation was concerned, in a very satisfactory condition, 
nearly free from elephantoid thickening, and with the flaps 
freely movable over the testicles. The right flap is the 
larger, and just at its most dependent part there is a circle, an 
inch and a half in diameter, of slightly elephantiased tissue. 
The cicatrix and penis are quite sound. Nearly over the 
whole of the scrotum, especially at the lower and back part, 
are scattered at wide intervals minute vesicles, milky-white, 
and no larger than pins' heads. They are arranged singly, 
in irregular grou^^s, and in short beaded lines. One of these 
vesicles I opened, and procured in a very short time a large 
quantity of milky-white coagulating fluid of the usual 
lymph-scrotum character. Perhaps in half an hour I collected 
two ounces. The inguinal and femoral glands of the left side 
are large and solid; those of the right side are nearly normal. 

I examined his blood carefully four times betwixt six p.m. 
and nine p.m., but it contained no filarise ; neither could I 
find any in the sediment of three ounces of scrotal lymph. 

The gradual passage of lymph-scrotum into elephan- 
tiasis can easily be understood, but this supervention 
of lymph-scrotum on elephantiasis is not so easily 
explained. I assume that the lymphatics carrying 
the lymph from the apparently sound operation flaps 
were damaged before the date of the operation, but 
only slightly so ; that gradually they are becoming 
more occluded from contraction at the seat of the 
original obstruction, and are now no longer capable of 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 109 

transmitting the entire production of lymph by the 
tissues. When the obstruction has become complete, 
and should the accumulating lymph not be discharged 
from the surface of the scrotum at short intervals, 
this man will certainly have a recurrence of his 
elephantiasis. 

6. Elephantiasis of the leg following operation for 
lymph-scrotum. 

I can imagine no stronger proof that elephantiasis 
and lymph-scrotum are but varieties of the same 
disease, than is supplied by this case. When the 
lymph-scrotum, or, in other words, the tissue per- 
mitting the escape of lymph, was removed by an 
operation, elephantiasis, or, in other words, complete 
stasis and organization of lymph, began. 

Case XVIII. Lymph-scrotum and elephantiasis of the 
scrotum combined; filarim in lymph and blood; operation; 
elephantiasis of leg developed (see Plate V.). — Oah, aged nine- 
teen ; a rice pounder from Khoan Kau, E-ong. No 
relatives, as far as he knows, affected with elephantiasis. 
E-ong is a small hamlet with about 100 inhabitants in 
the suburbs of Khoan Kau. The people drink well-water, 
which they store in large jars ; it is often kept for several 
days, no particular attention being paid to keeping the 
jars covered or clean. When sixteen or seventeen years of 
age the patient was frequently laid up with attacks of an 
evanescent fever, accompanied by a relapsing inflammation 
(it may have been of the testicle) in the right side of the 
scrotum, and enlargement of the right and left groin-glands, 
more particularly of the right. When fifteen he had an 
abscess in the left groin (scar is visible still), and another the 
same year in the right leg near the ankle ; at the time 
the whole leg was swollen (describes it as " toa kha tang," 
or " big heavy leg," the expression for elephantiasis). The 
swelling remained for about one month, but subsided on the 



110 THE FILAEIA SANGUINIS HOMINIS. 

bursting of an abscess, and now no tlaickening remains. The 
scrotal inflammation and the fever recurred about twenty 
times each year, but it was not until about a year ago that 
the scrotum discharged. When this happened it occurred 
daily for some time, and then dried up for about three 
months ; but for three or four months hardly a day has 
passed without an escape of lymph. When he came for the 
first time to the hospital there had been no discharge for 
several hours. A vesicle was pricked, and from then till 
the time these notes were made — four days — it has dripped 
constantly. In one hour I saw collected two ounces of a 
milky coagulating lymph. 

Four days subsequent to his admission to hospital I 
examined the scrotum carefully. He had it trussed up in 
a headcloth, on removing which a fine stream of lymph was 
forcibly projected by the contraction of the dartos, as if by 
a syringe, from a minute orifice at the lower part of the 
scrotum. Half an ounce ran in a fine capillary stream in 
the course of a couple of minutes. The scrotum was as 
large as an average pumelo. The skin of the penis was 
found to be distinctly elephantiased ; and the skin visibly 
and palpably thickened over both groins, the lower two 
inches of the abdominal wall, and over Scarpa's triangle on 
both sides. The upper and thigh surfaces of the scrotum 
were covered by a fine, silky skin, freely movable over the 
thickened substratum ; a little lower down the skin was 
thickened and adherent, as in elephantiasis ; lower still small 
ampullse were visible ; lower down these became larger, and 
along the raphe they were the size of small beans. Pricking 
any of these vesicles the usual fluid escaped. This was most 
distinctly a combination of elephantiasis and lymph-scrotum. 
The groin-glands were large, but they did not feel varicose ; 
however, on piercing a gland on the right side abundance of 
straw-coloured lymph was procm-ed; in this fluid I found 
filarise. I examined the lymph which dropped from the 
scrotum, and also blood from a finger, and in both of these 
found filaria embryos. During the short time required to 
make this note more than three ounces of fiuid distilled from 
his scrotum. In a few ounces of this fiuid a feeble coagulum 



PAEASITIC NATURE OF ELEPHANTOID DISEASES. Ill 

formed, whicli, in the course of eight or ten hours, contracted 
to about one-sixth the hulk of the fluid. The clot was then 
tough and fibrous. A small portion was removed, and 
placed between two glass slides, and fii^mly pressed out ; in 
the fluid thus expressed, surrounding and within the open 
meshes of the fibrine, were many living specimens of the 
filaria. I found none in the serum the clot floated in. It 
would appear, therefore, that the coagulating fibrine caught 
the filariae, and, contracting, carried them as in a net, thus 
concentrating them in the clot. Some of the filariee were 
very robust and active ; others again were languid, spotted, 
and shrivelled looking. In one such atrophied specimen the 
lash was quite visible with a low power, as were also many 
short fibres about y^-in. in length. Twelve hours after- 
wards the coagulum had completely disappeared ; a fiocculent 
sediment lay at the bottom of the glass, and in this great 
numbers of filarise were found. 

I removed this scrotum. Shortly after the operation the 
diseased tissues were found to weigh about a pound and a 
half. During the operation there was considerable bleeding, 
and also an escape of lymph from two dilated lymphatics, 
one on either side, just external to the spermatic cords. 
Firm pressure with the palm of the hand caused Ijrmph to 
well up in great plenty from these dilated vessels. This 
man was kept under observation for upwards of two months. 
The wound healed soundly, and the swelling of the glands 
decreased. His blood was examined daily, and during 
several days six times in the twenty-four hours ; but, unless 
the examination was made during the day, it was invariably 
found to contain embryos (see register, p. 37). Mos- 
quitos were also fed on his blood, and the embryos ingested 
by these insects were found to undergo the metamorphosis I 
describe (p. 13), confirming thereby observations made on 
several previous occasions. The mosquitos and scrotum 
were sent to Dr. Spencer Cobbold, and have been frequently 
examined by competent men in London. 

The diagnosis of lymph-scrotum passing into elephantiasis, 
subsequently, in this case, received singular and unquestionable 
confirmation. The man returned to hospital with his right 



112 



THE FILARIA SANGUINIS HOMINIS. 



leg, the flaps left at the operation, the cicatrix, and the in- 
teguments of the lower part of the abdomen, all in a typical 
state of elephantiasis. He stated that he had kept quite well 
for four months after leaving me (that is for six months after 
the operation), and was able to resume his rather fatiguing 
work of rice pounding. He was then attacked with elephan- 
toid fever, and pain in the right groin, and sometimes had a 
discharge of straw-coloured fluid from the operation cicatrix, 
and also from the thickened skin over the right groin and 
thigh. As he is covered vsdth itch, it is probable that this 
discharge was provoked by scratching. Three months ago 
the right leg inflamed and swelled up to a great size, and 
since then he has had three attacks of this inflammation, 
accompanied by elephantoid fever. He says he had also a 
large swelling at one time on the upper and inner surface 
of the left arm, which threatened to suppurate; but, after 
troubling him for ten or twelve days, it disappeared spon- 
taneously. The skin of the flaps and the cicatrix are rough, 
hard, and tuberculated, as in elephantiasis of some standing ; 
the skin over the abdomen and groins is coarse, and evidently 
considerably thickened ; while the swelHng of the thigh and 
leg is best described as brawny, the stagnant lymph being not 
as yet a solid tissue. The glands are so obscured by the 
overlying integuments that it is difiicult to make out posi- 
tively their exact condition, but those on the right side are 
certainly enlarged. Measurements of the legs give the fol- 
lowing results : — 



Eight. 



Left. 



Thigh at crutch 


... 21 1 inches 18| inches 


„ upper third 


. ... 22 , 


19 » 


„ middle 


. ... 20f , 


17 „ 


Knee 


... m , 


m „ 


Calf 


... 151- , 


m „ 


Ankle 


. ... 101 , 


81 „ 


Instep 


... lOi , 


9* „ 


Base of toes 


... 9f , 


qi 



One evening I examined his blood. One drop drawn at 
6.30 p.m. contained onefilaria; one drop drawn at seven p.m. 



PAEASITIC NATURE OF ELEPHANTOID DISEASES. 113 

contained fourteen filarise. It is evident from this persistence 
of embryos in the blood that the parent woims were not 
removed when the scrotum was amputated — at least, not all 
of them. From this fact, and the large number of embryos 
his blood contains, I believe there are several parent worms 
still in his lymj)hatics. The tumour he had on his left arm, 
which came and went so quickly, was, I have little doubt, 
caused by some obstruction of lymphatics brought about by 
filarise. 

7. Cases of lymph-scrotum and elephantiasis of the leg 
combined. 

Case XIX. Elephantiasis of the leg; lymph-scrotum; 
varicose groin-glands ; filarice in lymph from groin-glands 
and scrotum, and also in the blood (see Plate VI.). — Taikoan, 
aged twenty-eight ; a farmer from Tchiupo, Baepi. No 
elephantiasis in his family, but in his village of 700 or 800 
inhabitants he knows of four cases of elephantiasis of the leg, 
and four cases of elephantiasis of the scrotum. He drinks 
well-water of good quality, which, however, is stored in ajar, 
often for several days, and when the jar is refilled it is not 
always cleaned out. When thirteen years of age he had an 
attack of shivering and fever, with inflammation of the left 
leg and both groin-glands. He recovered in three or four 
days, but henceforward became liable to such attacks at very 
irregular intervals — sometimes only once or twice a year, 
sometimes as often as every month. With each attack the 
volume of the leg increased. The scrotum was similarly 
affected, and at the same time ; occasionally it discharged, 
perhaps daily, perhaps once in three or four days. He never 
had ohyluria. His body, generally, is in good condition. The 
right leg looks normal. The left leg is in a state of advanced 
elephantiasis, and a small ulcer has formed in front. Measure- 
ments are as follows: — 



Eight calf .. 


. 12 inches 


Left calf . . 


. 16 inches 


„ instep. . 


• m „ 


„ instep. . 


.14 „ 



The left foot is very much expanded in all directions, and its 
skin is thickened, glabrous, and in thick folds at the flexures. 

I 



114 THE FILARIA SANGUINIS HOMINIS. 

Tlie groin-glands on the left side are mucli enlarged, are 
soft, varicose, and very prominent. Those on the right are 
similarly affected, hut to a smaller extent, though still quite 
distinctly. 

The scrotum is an excellent specimen of a lymph-scrotum ; 
the contained lymph being sanguineous gives the parts a 
purplish tinge. A vesicle opened on the lower part emits, 
with considerable force, a stream of bloody lymph, and one 
can collect two or three ounces in as many minutes. 

August 14th, 1879. — ^At 6.30 this morning I aspirated the 
left groin-glands and got abundance of bloody lymph in which 
active filarise abounded. A quantity of this lymph, and also 
lymph from the scrotum, were put aside. At five p.m. the 
coagulum had contracted to one-third the bulk of the entire 
lymph ; it was bright red, and floated in a straw-coloured 
fluid. In coagulum from the glands, on tearing off a piece 
and compressing it firmly between two strong slides, I saw 
many filarise imprisoned in the fibrine, which restrained their 
movements, thereby making their detection rather difiicult. 
No filarise found in the serum of either gland or scrotal 
lymph. Next morning, twenty-four hours after the Ijrmph 
was drawn off, the coagula in both specimens had disappeared, 
and the coloured corpuscles, sinking as usual to the bottom of 
the glasses, formed a dark brown sediment. In this filarise 
were found, but not many. Blood from the finger, drawn at 
eight o'clock the previous evening, contained eight filarige to 
the drop. 

August 15th. — Aspirated, at seven p.m., the same gland, 
and most carefully searched two large slides full of lymph ; 
not one embryo found. Aspirated a gland on the right side, 
and examined most carefully one large slide ; not one embryo. 
The lymph from both glands was of exactly the same character 
as that drawn previously. About four drachms of lymph 
from each side was stood aside to await resolution of the 
coagulum and subsidence. Two slides of blood from the 
finger carefully searched, but no filarise found; however, 
when the blood was again examined at 9.30 p.m., fifteen 
filariee were found in one slide. 

August 16th. — Pierced another gland on the right side at 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 115 

six a.m. Bloody lymph in great abundance with plenty of 
filarise ; one slide contained six, another three ; one slide of 
finger blood contained one. At six p.m. the coagula of last 
night's lymph had disappeared, a dark-brown sediment and a 
milky fluid taking its place in both glasses. In a full, large 
slide of the sediment from the left side lymph I found four 
active fllariee, but in a similar slide of the right side lymph I 
could not find one. The lymph drawn this morning still 
coagulated ; but August 17th, six a.m, I note the coagulum 
had disappeared, and in one drop of sediment twenty-three 
active filarise were found. 

Case XX. Lymph-scrotum ; varicose groin-glands ; ele- 
pJiantoid condition of the skin of left, thigh; fllarice in Ixjmph 
from glands, but none in the blood. — Bek, aged twenty- 
eight ; a farmer from Tchiupo. Lives in a village with 
about 1,000 inhabitants, amongst whom he knows of two 
cases of elephantiasis of the scrotum, and two (a man and 
a woman) of elephantiasis of the leg. The woman is his 
mother. A brother and two sisters are healthy ; his father 
is dead, apparently of phthisis. 

The disease for which he applied commenced eight or nine 
years ago with fever, and two red, painful, and inflamed 
streaks on the inner surface of the left thigh, a little above 
the knee, and passing up to the groin. He says that the 
pain preceded the shivering and fever. The swelling at first 
was trifling, but similar attacks recurring about twenty 
times a year the swelling became more marked, and about a 
year ago the scrotum became inflamed and involved in the 
disease. The scrotum has inflamed now altogether seven or 
eight times. He never had chyluria, nor, unless when the 
leg and scrotum inflamed, fever. 

The integuments of the left thigh over its inner, anterior, 
and posterior surfaces are distinctly elephantiased from the 
knee to a point about two-thirds up the thigh. The rest of 
the limb appears to be quite normal ; but in the situation 
mentioned, the skin is darker than that on the corresponding 
part of the other thigh. It is also coarser, and cannot, 
especially about the centre of the affected patch, be pinched 
up in a fine fold, but feels brawny and as if anatomically 

I 2 



116 THE FILARIA SANGUINIS HOMINIS. 

continuous with, the subcutaneous tissue. Wlien one of his 
usual attacks of fever sets in this patch of skin becomes red 
and distinctly swollen. 

The groin-glands, both inguinal and femoral, and on both 
sides, are much swollen and are distinctly varicose. The 
scrotum is a good specimen of lymph-scrotum, and does not 
require further description. 

I introduced a subcutaneous syringe into one of the 
varicose inguinal glands on the right side, and easily obtained 
a supply of milky lymph. In this, during a short and hurried 
examination, I found one perfect and rather languid filaria 
embryo. A large slide of blood from the finger was exa- 
mined at the same time, but no filariee were found in it. On 
the f oUovwng morning I again aspirated the same gland, and 
procured a darker, and more bloody lymph ; lymph was also 
drawn from the left femoral and left inguinal glands ; in all 
of these, specimens of filarise were found. A slide of blood 
from the finger was examined at the same time, but, as on 
the previous day, it was devoid of embryos. The patient did 
not remain longer under observation. 

It may be objected that the affection of the skin of 
the thigh in this case was not elephantiasis. If it 
was not this, it is certainly a wonderful coincidence 
that his mother, who lived in the same house with, 
him, exposed to the same chances of filaria infection, 
should develope true elephantiasis of the leg. 

8. Elephantiasis of the leg with chyluria. 

I have only once met with this combination, but 
the circumstances of this case are so significant, that 
I request the readers' particular attention to the 
narrative. 

Case XXI. Elephantiasis of the leg ; varicose groin-glands; 
lymphous discharge from leg ; filarial in groin-glands, but 
tiot in blood ; subsequent development of chyluria. (Plate VII.) 
TcHENG, aged nineteen ; a paper gilder from Amoy. There 



PAHASITIC NATURE OP ELEPHANTOID DISEASES. 117 

is no elephantiasis in his family, nor, as far as he knows, in 
his neighbourhood. About ten years ago was attacked with 
shivering and fever, accompanied by swelling and pain in the 
right popliteal space. The fever and great pain continued for 
about a fortnight, ajid the swelling for a month or two 
longer. An abscess formed, burst, and healed ; but ever 
since a clear, yellow, lymphous fluid has distilled from the 
skin over the site of the abscess, and from the back of the 
calf of the leg. He says he has many attacks of fever everj 
year, accompanied by pain, but no particular swelHng of the 
leg or of the groin- glands. He has never had chyluria. 
His body is fairly developed for his age, notwithstanding the 
fever. The groin-glands, both inguinal and femoral, are 
much enlarged — those on the left side most so — and distinctly 
varicose. Those on the right — the side affected mth 
elephantiasis — are slightly varicose, but not so prominent as 
"on the other side, though still very large ; they are also 
much more dense and firm to the touch. On inserting the 
hypodermic needle into a varicose gland on the left groin, 
abundance of dark red fluid was withdrawn. The fluid 
coagulated rapidly ; and the coagulum disappearing after six 
hours, a copious dark red sediment collected at the bottom of 
the glass. In this sediment I found great numbers of living 
and active filarise. The bulk of the sediment was composed 
of corpuscles Hke those of blood. 

The right leg is enlarged from the upper third of the thigh 
downwards. Though rougher than healthy skin, the skin is 
not so rough, except on the foot, as it is in long-standing 
elephantiasis ; but it is dense, adherent to the subjacent tissues, 
and in every respect like the integument characteristic of that 
disease. From the ham to the lower third of the leg, the 
whole of the calf, and part of the sides and front of the leg 
are covered with a sort of weeping eczema. Examined care- 
fully the part of the skin thus affected is seen to be defined 
at its margin and slightly elevated, reddish on the sm-f ace, and 
finely papillated. No breach of surface can be detected, but 
on pressing firmly with the point of the finger a clear, yellow 
lymph is made to well up from the surrounding tissue, as if 
from a sponge. There are two firm elevations in the popli- 



118 



THE FILARIA SANGUINIS HOMINIS. 



teal region about tlie size of pigeons' eggs, rough, and encrusted 
on the surface, badly defined at the base, and yielding much 
discharge. These elevations represent the seat of the abscess. 
Unlike ordinary elephantiasis the calf of the leg is the least 
swollen part ; and it is just this part that the discharge issues 
from so copiously. Measurements of the legs : — 

Eight. Left. 

Upper thigh 19 inches 16 inches 

Middle „ 18* „ 16 

Knee 



Middle calf 
Heel 
Instep 
Toes 



18i 
18 

16 

12| 

10 



13 
12 
13 

9i 



Three large slides of blood from a finger drawn at seven p.m. 
contained no filarise. Next morning at six o'clock two more 
slides were carefully searched, but with the same result. The 
leg was dressed with zinc ointment, and I note a week after- 
wards that the discharge had considerably decreased, the leg 
feeling heavier and more stiff. Blood drawn from the finger 
at seven a.m. was again examined, but was devoid of filarise. 

Three days later I note : — " There is now little discharge 
from the leg. The right inguinal and femoral glands, with 
the exception of the most internal of the inguinal glands, 
feel more solidified. The latter gland is distinctly varicose. 

" The following are now the measurements of the leg : — 

Upper thigh 19 inches. ... Heel 16 inches. 
Mid thigh 18| „ ... Instep 12 „ 



Knee 
Mid calf 



18| 

19 

14i 



Toes 



9f 



" Left inguinal and femoral glands very prominent and 
distinctly varicose. At 7.30 p.m. subcutaneous syringe intro- 
duced into left inguinal glands, and sanguineous lymph 
readily obtained. About half an ounce was collected in a 
glass and left to stand. Before coagulation two large slides 
of this were examined, but no filarise were found. The syringe 
was again employed to abstract lymph from the varicose 
gland abeady described as the innermost of the enlarged 



PARASITIC NATUEE OF ELEPHANTOID DISEASES. 119 

glauds on the rig.lit side ; in one slide of this two languid 
filarise were found. 

" The glasses containing the specimens of lymph from both 
sides were now placed under cover to await resolution of the 
coagula, and the subsidence of any embryos they might con- 
tain. Twelve hours afterwards the coagula had contracted to 
one-sixth their original bulk ; they had become of a bright 
red colour, and floated in a milky serum. In the sediment of 
the fluid and in the coagulum from the left side, several live 
embryos were found during a brief examination. The exa- 
mination of that from the right side was very brief and 
imperfect, and discovered nothing. Next day, however, the 
coagula in both glasses had completely disappeared, and in 
the sediments of both many dead filariae were found. Blood 
from the man's finger drawn at 9.30 a.m. (?) contained no 
filarise." 

A fortnight later I note : — " Withdrew by the canula of a 
hjrpodermic syringe about six ounces of a slightly sangui- 
nolent lymph from the left inguinal glands, and also about 
two ounces of a similar fluid from the right inguinal glands. 
These, on coagulation and subsidence, after twenty -four hours, 
yielded a very few filarise in the sediments. Blood from the 
finger, drawn at ten p.m., yielded no filarise." 

The last of these notes was made on August 19th, 1879 ; 
the patient then ceased to attend, and I lost sight of him for 
two years. On August 3rd, 1881, he turned up again with 
bis leg and groin-glands pretty much in the same conditiun 
as they were two years before. But it was not on account of 
them he applied ; he came to ask if anything could be done for 
a chyluria which appeared about a month before. His urine 
is constantly loaded with sanguineous-looking lymph. It was 
collected every three hours for a day or two, and was always 
more or less chylous ; but, although the sediment was carefully 
examined, no filaria was found in it. 

August 5th, six a.m. — About two ounces of salmon-coloured 
lymph was removed by hypodermic syringe from the enorm- 
ously distended left inguinal glands ; the sediment from this, 
after resolution of the coagulum, was carefully searched, many 
slides of it, but for a long time no filaria was discovered ; at 



120 THE FILARIA SANGUINIS HOMINIS. 

last three dead specimens were found. Blood from the finger 
was examined on — 

August 4th, six p.m. and seven p.m., many times ; 

August 5th, 1.30 p.m., four p.m., six p.m., 6.30 p.m., 7.30 
p.m., nine p.m., and midnight ; 

August 6th, six a.m., 
but not a single filaria was found. 

On August 19th, I have a note that the sediment of six 
ounces of chylous urine was examined, but no trace of parasite 
was found in it. 

These cases are part of the clinical evidence on 
which, my belief in the parasitic causation of tropical 
elephantiasis is founded. The theory has been sub- 
jected to some amount of loose criticism, but no 
attempt of a serious or important character has been 
made, as far as I know, to explain away the inter- 
pretation I put on the facts I have recorded. Some- 
thing has been said about coincidence, but surely the 
frequent combination of lymph-scrotum and elephan- 
tiasis is not in every case coincidence ; nor is it fair 
to say that the supervention of chyluria in the case 
last narrated is simply coincidence. By such argu- 
ment it would be possible to explain away every 
theory in pathology. Much has been made, too, of 
the absence of filarise in the blood in fully-developed 
elephantiasis. But I have narrated several cases of 
lymph-scrotum in which they were absent in that 
.fluid, yet were found in the lymph. It is nearly 
I impossible to get gland-lymph in elephantiasis ; were 
it otherwise we might find filariee, or the remains of 
them, in it. Besides, we know that the parasite, after 
working much mischief, dies in some cases. May 
there not be something in the conditions of lymph 
circulation, or obstruction, in ordinary cases of ele- 



PARASITIC NATURE OF ELEPHANTOID DISEASES. 121 

phantiasis, inimical to the life of the parasite which 
produced them, or that renders it impossible for its 
embryos to gain admission to the general circulation ? 
A n evan escent jBmise_ often, in pathology, produc es a 
permanent effect. The gravid womb by pressure 
causes varicosity of the veins of the legs which does 
not disappear after parturition. Constipation in the 
same way causes haemorrhoids ; rheumatic inflam- 
mation of the valves of the heart permanent heart- 
disease, and so on. In the same way in elephan- 
tiasis, the parasite, after permanently damaging the 
lymphatics, disappears. 

If we do not accept the parasitic theory as explain- 
ing tropical elephantiasis, then we are obliged to con- 
clude that in the tropics there are two forms of this 
disease ; that they affect the same parts of the body ; 
are found in the same districts ; are characterized by 
the same sort of fever, inflammation of the lympha- 
tics, and skin-lesions ; that in fact they are in every 
respect identical, and only differ in their aetiology. 
I think this is so unlikely that few on reflection will 
maintain it. 



CHAPTEE VL 

CLINICAL EVIDENCE FOR THE THEORY THAT THE ELE- 
PHANTOID DISEASES ARE CAUSED BY EMBOLISM OF 
THE LYMPHATICS BY THE OVA OF THE FILARIA. 

i The clinical evidence for the theory that the ele- 
phantoid diseases are caused by embolism, of the 
lymphatics by the ova of the filaria arranges itself 
under two heads. 

1. Cases to show that a frequent habitat of the 
parent parasite is the lymphatic trunks on the distal 

' side of glands. 

2. Cases in which the ova of the parasite were 
found in lymph from the distal side of the glands. 

1. Cases to slioiv that a frequent hahitat of the 
parent parasite is the lymphatic trmiks on the distal 
side of glands. 

I have already referred to the "finds" of the 
parent worm by Bancroft and Lewis. In these 
instances, the worm was certainly found on the distal 
side of glands. I have also given several cases in 
which the young of the parasite were found in gland- 
lymph and yet were absent from the blood, giving 
presumptive evidence that the parent must also have 
lain on the distal side of the glands. The two follow- 



THEORY OP ELEPHANTOID DISEASE. 123 

ing cases prove that she, sometimes, at all events, lies 
there. The first case is the one referred to at page 1. 

Case XXII. Lymph-scrotum; filaria embryos in lymph 
from scrotum, hut not in blood; excision of part of the 
scrotum; parent filaria in dilated lymphatic. — Ph^, aged 
forty-six ; a pedlar and farmer from Phoolamkio, lu 
Khse. Four or five years ago he noticed that after 
much walking had pain in both groins and along the 
course of the spermatic cords, but he says it was never, or 
very seldom, associated with fever. He has never had in- 
flammation or abscess of the scrotum. At first there was 
swelling of, and pain in, the groin-lymphatics ; but on the 
bursting of a vesicle which had formed on the scrotum, and 
the discharge of much fluid, these subsided. During the 
first year or two scrotal discharges occurred only once or 
twice ; then, they became more frequent, and during the last 
three months the discharge has been nearly constant. It 
may stop for a day or two occasionally, but, as a rule, the 
scrotum drips lymph night and day, perhaps to the extent of 
ten to fifteen ounces in the twenty-four horn's. The dis- 
charge, he says, is always clear like water, and when 
collected in a bowl, coagulum, with red particles and streaks 
on it, forms rapidly. He has never had chyluria nor any 
serious illness. 

October 11th, 1880. — Inguino-femoral glands on both 
sides enlarged, especially on the right side ; they are neither 
distinctly varicose nor firmly indurated, but have a soft, 
spongy feel. The bulk of the scrotum is only shghtly 
increased, but everywhere on its dusky-red surface are 
scattered innumerable minute vesicles, varying in size from 
a No. 6 to a No. 2 shot. Pricking any of these permits the 
escape of a clear watery lymph. As I examine the scrotum 
this fluid, oozing from some ruptured vesicles, drips con- 
stantly. The right testicle is absent, probably undescended ; 
there is no hydrocele on the other, which feels large and 
healthy. The under surface of the sheath of the penis is 
somewhat swollen, but is not vesiculated. The scrotum is soft 
and silky. There is no elephantiasis or swelling of the legs. 



124 THE PILARIA SANGUINIS HOMINIS. 

The clear watery character of the lymph is peculiar. I 
found in a short examination of sediment of some drawn at 
eleven a.m. to-day one embryo filaria. I collected two 
other specimens of lymph, one drawn between four and 
five p.m., the other at seven p.m., and stood the three lots 
to await resolution of coagula. Blood drawn from the 
finger at 7.45 p.m. had no filarise ; again, at eight p.m., 
examined a large slide, but found no filariee. The blood is 
very watery and deficient in corpuscles. 

October 12th. — Examined the sediment of the three 
specimens of lymph and found embryo filariee in all of them, 
two or three in eveiy slide of sediment. It is evident from 
this that the filarise observe no periodicity while ' they 
are in the lymph, and that reproduction is a continuous 
process. 

In this case I believe the obstruction in the lymphatic 
circulation is very low down, probably not higher than the 
inguino-femoral glands, and that it is complete ; because, 
1st, had the lymph regurgitated after passing through 
glands it would probably be milky, or sanguineous, and 
much richer in corpuscles than it is ; 2nd, it is clear and 
watery, as it is near the radicles of the lymphatics ; 3rd, 
there is an absence of marked varicosity of the lymphatic 
glands it first reaches — were the obstruction higher up the 
lymph cu'culation those lower glands would be distended by 
accumulating lymph ; 4th, filariee in the lymph, but not in 
the blood — proving that the obstruction is complete. I 
think it probable, considering these facts, that the parent 
worm is between the surface of the scrotum and the first 
lymphatic glands, and that we will find it when the scrotum 
is excised. 

October 15th.— Eemoved part of the scrotum this forenoon. 
The dripping of lymph continuing I thought it advisable to 
operate to save this man's life. As he lay on the operating 
table under chloroform I could see the anterior border of 
the spleen bulging out the relaxed and wasted abdominal 
muscles, and could feel that the organ was very much 
enlarged. Under such circumstances I generally abstain 
from all serious operations, but when I recollected the 



THEORY OF ELEPIIANTOID DISEASE. 125 

corpuscleless and watery state of the Hood, the absence of a 
history of malarial fever— the usual cause of splenic tumour 
here — the probability that it was the result of the state of 
the blood, and that this again was caused by the constant 
day and night dripping of lymph from the scrotum, I 
determined to proceed. The operation was a very simple 
affair. I dragged down the affected portion of the scrotum 
till it was clear of the testicle, transfixed the fold thus 
formed with a finger-knife, cut upwards and then downwards, 
removing a circle about two and a half or three inches in 
diameter of soft, spongy, watery scrotum. Only three arteries 
required ligature. Pressure with the palm of the hand over 
the right inguino-femoral glands forced from a varicose 
lymphatic in the upper and right comer of the wound a 
stream of lymph the thickness of a fine knitting needle, and 
vdth a projection of three or four inches. The lymph thus 
expressed was clear and watery. I failed to do the same on 
the left side. The solitary testicle — the left — was healthy. 
The edges of the wound were brought together and united 
with catgut sutures. 

The scrotum, when excised, had been placed in a clean 
bowl, and when the operation was finished I took it up 
and carefully examined the cut surface. Finding nothing 
unusual I folded it up, intending to examine it at my leisure. 
However, being curious about my prognostication, I took it 
up again and unfolding and exposing the cut surface, saw 
wriggling on it very vigorously a long and slender worm, of 
a cat-gut, opaline look, the thickness of a medium-sized horse- 
hair. One end of the worm was free, the other entered 
the cut end of the lymphatic corresponding to that from 
which I expressed the lymph on the right side. About two 
inches of the worm was free. I tried to coax out the rest 
with my finger, but failed. The worm appeared to be work- 
ing back again into the scrotum. Fearing it would succeed 
in this I laid it on the handle of a scalpel. When it had 
partly dried and adhered, I made gentle traction ; but the 
worm snapping in the vessel, I procured only about two 
inches of the free extremity, with long pieces of uterine tubes 
and alimentary canal dangling from the transverse fracture 



126 



THE riLARIA SANGUINIS HOMINIS. 



of the integument. I did not attempt any further examina- 
tion of the scrotum (which contains the caudal end of the 
female, and probably the male worm), but placed it in spirits 
and sent it to England. Dr. Bennett, of H.M.S. Sioinger, 
was present at the operation, and saw the worm. 

The same evening I examined with the microscope that 
part of the worm I had broken off. It was the head end of 
a female. The body was quite plain, without markings, 
and tapered rather abruptly to the simple, somewhat club- 
shaped mouth. The vagina opened about i^r-^- from 
the mouth ; the uterus was packed with embryos at every 
stage of development. In the lower part of the uterine tubes 
the embryos lay at full length, outstretched as we see them 
in the blood ; the sheath was very distinct in one of the 
embryos that had escaped from the vagina. The worm was 
certainly viviparous. The following are my measurements, 
carefully made : — 



Greatest diameter of body 
Diameter of alimentary canal 
,, head at shoulder 

Orifice of vagina from mouth 
Diameter of body at vagina 
Ova before differentiation of embryo, 

cleavage comjolete ... -^ 

Ova after differentiation of embryo ^ 
Diameter of uterine tubes 
Free embryo ... ... ... gV'iii- ^ 

Length of sheath visible beyond the head 

of the free embryo 



— 1 ITl 

y n ■'■"■' 

4 To -in. 

T5-in. 

xT5-in^ 



T-m. X 



in. X y^o-in. 

... idnr-in. 

_' in 

■^-"* 
1 



TW-m. 



The animal was mounted in urine (of a specific gravity 
similar to that of lymph) for examination and measure- 
ment. In such a medium the parts retain their natural 
proportions ; if mounted in water, glycerine, or spirits there 
is often much distortion, and an incorrect idea of relative and 
actual size produced. 

October 15th. — Doing well. A slide of blood drawn at 
5.30 p.m. from the finger contained no filarise. 



THEORY OF ELEPHANTOID DISEASE. 127 

October 16th. — One slide of blood drawn at 5.30 a.m. 
contained no filariae. 

October 26th. — Had an attack of fever yesterday, and he 
is still hot. The sheath of the penis is considerably swollen, 
but otherwise the case is doing well ; the wound is granula- 
ting kindly, and there has been no escape of lymph since the 
operation. 

November 3rd. — Wound nearly healed ; swelling of penis 
subsided. Patient, who has been taking large quantities of 
iron, much stronger ; blood still very deficient in corpuscles ; 
spleen smaller ; one slide of blood drawn at six p.m. contained 
no filarise. 

November 6th. — Wound healed ; no filarise in the blood ; 
going home to-morrow. 

Case XXIII. Abscess in the thigh caused by the death of 
the parent filaria ; varicose groin-glands ; fragments of mature 
worm in the contents of abscess. 

January 7th, 1881. — A middle-aged, well-nourished man 
came to hospital to-day with a large, hard, brawny-red 
swelling in the upper and inner part of the right thigh. An 
abscess was evidently forming. I observed that the corre- 
sponding femoral glands are somewhat enlarged, softish, and 
not inflamed ; and he said they had been swollen long before 
the present trouble began. He also had had fever, apparently 
lymphatic. Accordingly, I concluded that the glands were 
filarious, and that their enlargement was not secondary to 
the inflammation then existing. I drew off from them with 
a hypodermic syringe some milky lymph. In this a very 
imperfect and hurried search was made for embryos, but 
none were found. Diagnosis. — Abscess caused by death of 
parent filaria in lymphatics. Pus, apparently, had not 
formed, so mercurial ointment was ordered to be rubbed into 
the swelling, and poultices to be applied. 

January 10th. — Returned this morning in great pain; 
matter had formed. Free incision gave vent to about four 
ounces of dark yellow-brown pus, in which floated two or 
three dark clots of blood, evidently effused for some time. 
The pus and clots were all collected, and this evening. I care- 



128 



THE FIEARIA SANGUINIS HOMINIS. 



fully searched them. By drawing a needle rapidly through 
the pus I succeeded in entangling three or four fibres, which, 
on being subjected to microscopical examination, proved to 
be fragments of a mature female filaria. In one fragment 
were large numbers of fully-formed outstretched embryos, all 
dead and granular, great bunches of them escaping from 
rents in the wall of the uterus ; other fragments were 
crowded with o'm at an earlier stage of development (see 
illustration). 




Fragment of Female Filahia Sanguinis Hominis prom Abscess in 

Thigh, sho^ving Remains of Alimentary Canal, Decomposing 

Body, Dead Embryos escaped from RtrpTFRED Uterits ; 

one OvtTM VISIBLE. 

January 25th. — Filarise have been found in this man's 
blood every night till date. To-night I found two active 
specimens in a slide of finger-blood drawn at seven p.m. The 
wound is healing, and the surrounding induration has dis- 
appeared; but the glands, especially the femoral, are still 
swollen on the right side. He tells me that these glands have 



THEORY OF ELEPHANTOID DISEASE. 129 

been big — but on this side only — for over ten years, and 
tbat once, long ago, they were inflamed. For a year or 
two he lias had very little fever, but formerly was more 
subject to it. 

January 28th. — This afternoon pierced the enlarged 
femoral glands and drew off, rapidly dropping, about two 
ounces of salmon-coloured lymph. (Dr. Jamieson of Shanghai 
was present.) In one slide of this lymph found a very 
languid and faintly granular embryo. One slide of blood, 
drawn and examined at six p.m., contained one active embryo. 

February 14th. — Two drachms of lymph di'awn from 
glands. A full slide of this contained twelve active filarise. 
One of these, examined with a high power, looked perfectly 
healthy and normal. 

This man remained under observation for about two months 
after the abscess was opened, and therefore after the death 
of the parent filaria which was connected with the enlarged 
femoral glands ; yet, during all this time, his blood contained 
at the usual hours a fair stock of embryos — apparently as 
many at the end of the two months as at the beginning. It 
is fair to infer from this, either that there were other mature 
female worms alive in his lymphatics ; or, if the dead speci- 
men removed from his thigh was the only one, that the 
young filarise keep alive for several months both in lymph 
and blood. 

These two cases are of themselves conclusive proof 
that a habitat of the parent filaria is the lymphatic 
trunks on the distal side of glands. The two 
following cases corroborate this statement likewise, 
for they prove that the ova of the worm have been 
found in these lymphatics ; and, the ova having been 
found thei'e, it necessarily follows that the parents 
that gave birth to them must have been in the distal 
lymphatics. 

2. Cases in which the ova of the parasite were found 
in lymph from the distal side of glands. 

K 



130 THE FILARIA SANGUINIS HOMINIS. 

Case XXIV. Filarim in blood; enlarged^ indurated, and 
'partly varicose groin-glands ; elephant o-oedematous legs ; ova of 
filaria in lymph from groin-glands. — Oh, aged forty -four ; a 
farmer from Tchangtoliiu, Toana-sia. No elephantiasis in 
his family. There are about 1,000 inhabitants in his 
village. Years ago, he recollects, there was a man with a 
big elephantiasis scroti, who was killed by the Taiping 
rebels. The little boy who brought the patient to hospital 
has a huge elephant leg. Besides these he knows of no 
other cases of elephantiasis in his village. He generally 
drinks well-water, but when working in the fields often 
drinks from the paddy-field runnels. The well-water is 
stored in a jar, without a cover ; the jar is filled every 
second day, but cleaned only once every five or six days. 

He says he has had enlarged glands since boyhood, but 
never had pain or inflammation in them, nor have the}* 
altered in appearance much during many years. When very 
young — about twenty — had quartan ague for a month or 
two, but until last year had, on the whole, excellent health. 
Last year, however, in the fourth month, after indulging in 
a little wine, he fell asleep, and when he woke up had 
rigors followed by fever, but not so severe, as to prevent him 
working. He noticed that his legs, both of them, had 
swollen. They remained enlarged for eight months, and 
on the inner side of the left thigh a pustular-like eruption 
broke out. By the beginning of the present year eruption 
and swelling had quite subsided, and he was in his ordinary 
state of health. In the fourth month he had a severe attack 
of fever and diarrhoea, dming which the legs swelled again 
and acquired their present appearance. In the morning 
they are less, in the evening larger. 

When he presented himself at the hospital he was 
excessively anaemic, but the swelling of the legs was 
too brawny for the ordinary oedema of anaemia, yet too 
soft for the hypertrophy of elephantiasis. It readily pitted 
on firm pressure. The heart and urine were normal. 
The inguinal and femoral glands on both sides are much 
enlarged, and in shape characteristic of filaria san- 
guinis hominis; but they are fiimer and more solidified 



THEORY OF ELEPHANTOID DISEASE. 131 

than those generally met with in Ijonph-scrotum, and softer 
than those usually associated with elephantiasis. One gland 
in the left groin — the uppermost and outermost — felt 
slightly softer than the others, and a hypodermic syringe 
drew off from it a small quantity of perfectly clear lymph. 
.In this lymph I found eleven ova, presumably of filar ia 
hanguinis hominis, and one languid free embryo. The ova 
jwere all advanced to the last stage of development; each 
contained a perfect embryo, which moved about inside the 
delicate wall in a rotatory fashion, just as I had seen the 
embryos of filaria immitis of the dog, when they had 
descended close to the vaginal end of the uterus. The ova 
were oval, the extremities of the long diameter having a 
tendency to "point." Their dimensions were 3-^-^-in. x 
y]-o-in. I saw no trace of lash in the embryo. In one 
slide of blood from the finger, taken at the time the lymph 
was abstracted from the gland (early in the morning), four 
filarise were found. Two days afterwards I pierced the 
same gland and abstracted a small quantity of bloody 
lymph. In this I found neither ova nor embryos ; but 
following the needle, as it was withdrawn, there escaped a 
drop or two of bloody Ijonph, and in this I found thirty-five 
active and free embryos, but no ova. At the time of this 
last examination blood from the finger contained twelve 
embryos to the drop. A similar examination, made two 
days later, yielded one embryo in the lymph, but no ova. 

Case XXY. Lymph-scrotum; filarim in lymph from 
scrotum, also ova containing coiled-up and active emhryos ; small 
number of parasites in the hlood : operation. — Tui, male, aged 
fifty ; Tchangtchiu, Khiotau ; a farmer. There are some 200 
to 300 inhabitants in his village, including several cases of 
elephantiasis. One, called Benga, I operated on some years 
ago, removing a 12-lb. scrotum. 

When young was careless about the water he drank, taking 
it indiscriminately from pool, well, or river. When a Little 
over ten years of age had frequent attacks of ague, both 
quotidian and tertian. His scrotal trouble began at eighteen. 
He had hydrocele then, and at times inflammation of the 

K 2 



132 THE riLARIA SANGUINIS HO MINIS. 

scrotum and lymphous discharges. Two years ago, he says, 
I tapped his hydrocele. I forget the circumstance and the 
character of the fluid withdrawn ; as I did not inject iodine, 
doubtless at the time I considered the hydrocele to be of 
filarious origin, although he says the fluid removed was clear 
and straw-coloured. The hydrocele did not return, but the 
scrotum enlarged. He has attacks of fever and enlargement 
of the groin-glands ; and, irregularly, some three to ten times 
a month, the scrotum discharges a clear fluid, very like urine 
in appearance. 

May 18th, 1881. — The scrotum is as large as a pumelo, and 
the penis is buried in it ; the upper and anterior part is firm, 
like a forming elephantiasis, while the lower and back part is 
covered with enormously dilated lymphatics, some of the 
ampullae, containing clear fluid, being as large as the tip of a 
finger. 

Seven p.m. — Pricked a vesicle ; profuse discharge of fluid, in 
which I f oimd fllarise. A slide of blood from the finger, drawn 
at nine p.m., contained no parasites. 

May 19th, six a.m. — Slide of finger-blood examined; no 
filarise. Lymph drawn last night again examined ; it had 
coagulated but feebly ; it again yielded filarise. The feeble 
coagulum was now broken up by stirring. It rapidly dis- 
appeared, a small quantity of red deposit and some white 
cloudy flocculi subsiding. In this sediment were many 
embryos ; and, in nearly every slide, ova with active embryos 
struggling vigorously to stretch their chorional envelopes. 
No double outline could be detected in the embryos. The 
chorion could be distinctly made out, especially when the 
activity of movement had somewhat subsided. 

May 20th. — An assistant examined a large slide of blood, 
drawn at ten p.m. last night, and in it found one embryo ; and, 
again, at six a.m. to-day, but then found none. I examined 
several slides of sediment from the lymph of the 18th, and 
found embryos still alive, many of them enclosed in an oval 
or nearly globular sac, and two specimens in which the 
chorion was half stretched. These latter embryos were still 
working vigorously, but had not quite completed the stretch- 
ing operation, as a third of either anterior or posterior end 



THEORY OF ELEPHANTOID DISEASE. 133 

was still doubled on the rest of ttie body, no room having as 
yet been gained for the animal to lie completely outstretched. 

In this man a very few embryos still found their way into 
the circulation, but there certainly was no fi'ee communication 
between the lymphatics of the scrotum and the blood. 

May 21st. — Scrotum removed, skin of penis being pre^ 
served. I quite expected to find the parent worm in this 
case, but although the scrotum was cut up into very small 
pieces and carefully searched no trace of the animal was 
observed. The tissues were much more dense than is usual 
in lymph-scrotum, and their bulk was considerably greater 
than obtains in the generahty of these cases. In fact it 
appeared, but for the vesicles and discharge, more like an 
ordinary case of elephantiasis. No lymph could be made to 
regurgitate by pressure on the groin-glands. 

June 10th. — Case doing well. Since the operation the 
blood was frequently examined, and at suitable times, but no 
filarise were found in it. 



CHAPTEK VII. 

DISTOMA RTNGERI ATSTD ENDEMIC HEMOPTYSIS.* 

(Plates YIIL, IX.) 

The list of parasites inJiabitiiig the human body is 
gradually becoming a long one ; another addition — 
the latest, I believe — has been recently made by 
Dr. Einger, of Tamsui, Formosa. 

The following notes embrace all that is yet known 
of the new ]3arasite. 

Some time ago, November 6th to December 18th, 
1878, I had in hospital here (Amoy) a Portuguese 
suffering from symptoms of thoracic tumour, pre- 
sumed to be an aneurism. He improved with rest 
and treatment, and returned to Tamsui whence 
he had come, and where he had resided for 
many years. He did not live long after his 
return. He died suddenly (June, 1879) from 
rupture of an aneurism of the ascending aorta into 
the pericardium. Dr. Einger made the post-mortem 
examination, and, knowing I took an interest in the 
case, kindly wrote me the particulars of the exami- 
nation. Besides describing the immediate cause of 

* Eeprinted from "Customs Medical Eeports," No. 20, 
p. 10. 



DISTOMA RINGERI AND ENDEMIC HiEMOPTYSIS. 135 

death, he told me he had found a parasite of some sort 
in making a section of the lung, and promised to send 
the animal to me for inspection. He wrote : — 

" After making a section I found the parasite lying 
on the lung-tissue — it might have escaped from a 
bronchus. Whilst alive a number of young (micro- 
scopic) escaped from an opening in the body There 
were some small deposits of tubercle, no cavities, 
and, if I remember aright, slight congestion of the 
lungs." 

Last April a Chinaman consulted me about an 
eczematous eruption he had on his face and legs. 
The eruption had been out for some time, and had 
its origin, he believed, in an attack of scabies. 
Whilst he was speaking to me, I observed that his 
voice was rough and loud, and that he frequently 
hawked up and expectorated small quantities of a 
reddish sputum. At that time I was making exami- 
nations of lung-blood in connection with another 
subject, and as this man's sputum afforded a favour- 
able opportunity for examination I placed a specimen 
under the microscope. The sputa, which to the naked 
eye appeared to be made up of small pellets of rusty 
pneumonic-like spit, specks of bright red blood and 
ordinary bronchial mucus, contained besides ordinary 
blood and mucus corpuscles, large numbers of bodies 
evidently the ova of some parasite. These bodies 
were oval in form, one end of the oval being cut 
off and shut in by an operculum, granular on the 
surface, blood-stained, measuring on an average 
-3^-in. X 5^^0-in. Firm, pressure on the covering 
glass caused them to rupture and their contents to 
escape, the shell being left empty and fractured at 



136 DISTOMA RINGERI 

the opercular end. Though empty the shell had a 
]}ale brownish-red colour. 'No distinctly organized 
embryo could be made out in the uninjured ovum, 
but when the contents were expressed they resolved 
themselves into oil masses, and granular matter 
having very active molecular movements. A delicate 
double outline could be made out in most of the ova. 
They were so numerous that many fields of the micro- 
scope showed three or four of them at once. 

Two days afterwards I again examined this man's 
sputum, and found it full of ova as on the previous 
occasion. I asked him to come again, and to supply 
me from time to time with sputum, but he did not 
return, and has left the neighbourhood, I believe. I 
hoped to attempt successfully the hatching of the ova, 
as has already been done in the case of other disto- 
mata ; but his disappearance, and my failure to get 
another and similar case, oblige me to postpone the 
experiment. 

At his first visit I obtained the following parti- 
culars of his case : — 

Case XXYI. — Tso Tong, male, aged thirty-five ; native of 
Foochow ; a secretary in the salt office ; resident in Amoy 
about one year. He was born in Foochow city, and lived there 
till he was twenty-one years of age ; he then went to Teokt- 
cham, a town in North Formosa, about two days' journey from 
Tamsui, and resided there for four years ; then he returned 
to Foochow for a year and a half. He was again sent to 
Tecktcham for a second service of four years. He returned 
again to his native town for a year, and was then sent for 
six months to Henghwa. Afterwards he lived successively 
in Foochow, one year ; Amoy, a year and a half ; Foochow, 
four months ; and again Amoy for one year, where he is at 
present stationed. A year after his first arrival in Tecktcham, 
when he was twenty-two years of age, he first spat blood. 



AND ENDEMIC HiEMOPTYSIS. 161 

Every day for nineteen days he brought up from half an 
ounce to an ounce of blood ; he emaciated slightly, but had 
very little cough. Ha3moptysis returned about six months 
later, smaller in quantity, but, as in the former attack, the 
blood at first was pure, immixed with mucus, and of a bright 
red colour ; this second attack lasted for a few days only. 
Since then he has spat blood for two or three days at a time 
in small quantities every second or third month. He has 
never had much cough, and he says that the blood is always 
mixed with mucus after the first mouthful. Once, during two 
years, he had no blood-spitting. Though rather thin he 
enjoys good health. I could discover no signs of lung- 
disease on auscultation. His father is dead, but not from 
cough ; his mother, who died ten years ago, had a cough. He 
has had two brothers and two sisters ; they are all of them 
alive and in good health. 

When I discovered the ova in this man's sputum I 
recollected Dr. Einger's parasite, and that the Portu- 
guese in whose lung it was found had also for many 
years lived in ]N"orth Formosa ; and I came to the 
conclusion that this Chinaman's lungs probably con- 
tained a similar parasite, and that it was the cause of 
the blood- spitting. At my request Dr. Ringer sent 
me the solitary specimen he had found a year before. 
It was preserved in spirits of wine. I placed a little 
of the sediment in the spirit under the microscope, 
and found in it several ova of the same shape, colour, 
and dimensions as those I some time before found 
in the Chinaman's sputum. Most of the ova were 
ruptured ; a few, however, were still perfect. 
The parent parasite was spatula-shaj)ed, of a light- 
brown colour, firm leathery texture, and measured 
^-in. X 3^2 "i^- X 3~2~ii^- It was evidently a distoma; 
but not feeling quite sure if it was a new species or 
not, I sent it to Dr. Cobbold. He pronounced it to 



138 DISTOMA EINGERI 

be new, and .has named it distoma Ringeri^ after the 
discoverer. Eef erring to the specimen, he says : — 

" I satisfied myself that the fluke was new to science, and 
accordingly I propose to call it distoma Jtingeri, after the 
discoverer. Though mutilated, the oral sucker was well 
shown, as also were traces of an organ which I regarded as 
the remains of the ventral acetabulum. When flattened on 
a glass shde, the capsules of the vitellarium were well seen, 
and occupied fully four-fifths of the body, lying deep under 
the dermal surface. The worm reminds me very much of 
distoma comjMcktm., which many years ago I detected in the 
lungs of an Indian ichneumon, but it is much larger and 
evidently a distinct species." (" Journal of the Quekett 
Microscopical Club," No. 44, August, 1880). 

We are as yet not in a position to say much about 
the pathological significance of this parasite. I do 
not think it common in this locality, but when prac- 
tising in South Formosa I recollect seeing many 
cases of chronic and oft-recurring blood-spitting with- 
out apparent heart or lung lesion, and it is just 
possible that the heemoptysis in many of these cases 
was caused by distoma Ringeri. My patient told 
me blood-spitting was a very common complaint in 
Tecktcham. 

The intermediary host or hosts, the geographical 
distribution, and the mode of entrance of the parasite 
into the lungs offer a very interesting field for future 
investigation. 



Distoma Eingeri and Endemic Haemoptysis — 
• continued* 
In the " Customs Medical Eeports," vol. xx., page 
* Eeprinted from " Customs Medical Eeports," No. 22. 



AND ENDEMIC HEMOPTYSIS. 139 

10, I called attention to a new parasite, the mature 
form of which had recently been discovered by Dr. 
Einger in Tamsui, Formosa. I therein succeeded in 
associating this animal with a peculiar form of recur- 
ring heemoptysis, common in one part at least of the 
Chinese Empire, which had hitherto not been under- 
stood ; and I gave some particulars of a case occur- 
ring in my own practice, in which the association was 
apparent. At that time I was unaware that Pro- 
fessor Baelz, of Tokio, had been working at the same 
subject, and it was not until I read, in the " Lancet" 
of October 2nd, 1880, a summary of a paper by this 
gentleman, that I learned that this disease had been 
described by him, and that it was not uncommon in 
Japan. Although Professor Baelz, in the paper I 
refer to, errs in calling the bodies which I have proved 
to be the ova of distoma Ringeri^ gregarinse, yet, 
though I do not know the dates of his investigations, 
the merit of priority in the discovery probably rests 
with him. 

In my report I mention that in making a post- 
mortem examination of a Portuguese dead of aneurism 
of the aorta, Dr. Ringer found a parasite in the lungs ; 
that in the sputum of a Chinaman suffering from 
a chronic intermitting haemoptysis I found certain 
bodies I had no difficulty in recognizing as the ova of 
a parasite ; and that when these bodies and the ova 
emitted by distoma Einfferiweve compared, they were 
found to be identical in size, shape, colour and con- 
tents. 

Of the parasite discovered by Professor Baelz, the 
'' Lancet " says that it is 
- " Met with in two forms : (1) as yellowish-brown ovoid 



140 DISTOMA RINGERI 

bodies of "13 mm. long and "07 mm. wide. They have a 
double contour, from a translucent wall, -02 mm. thick, which 
in different positions appears greenish or reddish, and at the 
larger end is a kind of cover, at which the cyst opens. The 
contents consist of delicate jeUy-like material, in which are 
imbedded three or five aggregations of smaller bodies. The 
latter consist (a) of splierules about twice the size of a white 
blood-corpuscle, colourless, with sharp outlines. Around 
these spherules, and more or less enclosing them, is (b) a 
coarsely granular material scattered through the jelly, and in 
it molecular movements may often be seen. When the 
spherules have left the cyst, they show for a time the same 
movements, and then become invested with the granular 
substance, and become motionless." 

These Ibodies, he concluded, are a stage in the 
development of gregarinse, and he therefore proposes 
to call the disease they are connected with gregarU 
nosis pulmonmn^ and the parasite gregarina pulmonwn 
or gregarina fusca. 

As the above description applied pretty accurately 
to the ova of distoma Ringeri^ and as they were asso- 
ciated with hsemoptysis, I concluded they were iden- 
tical, and wrote to Professor Baelz, requesting him 
to send me a specimen of the characteristic sputum 
from Japan. He very kindly did so, and I had no 
difficulty in seeing that the bodies he described were 
identical with those I was familiar with, and with the 
ova of distoma Ringeri. Indeed, in his letter to me, 
the professor says that both he and Leuckhart had 
already suspected they might be the ova of a distom. 
That this view is the correct one will receive addi- 
tional and corroborative evidence in the sequel. 

During the last eighteen months I have made many 
unsuccessful attempts to find the ova of the parasite 
in the sputa of natives of this district. I suppose I 



AND ENDEMIC HEMOPTYSIS. 141 

have examined altogether about 150 individuals. 
Therefore, it is not at all likely that the disease is 
common in Amoy and its neighbourhood. It is quite 
otherwise, however, in l^orth Formosa, though only 
separated from us by some 200 miles of sea. Being 
anxious to attempt the development of the embryo, 
and despairing of finding supplies of ova in Amoy, I 
applied to my friend Mr. John Graham, of Tamsui, to 
find me some sputa. He answered my letter by send- 
ing me two bottles full of ova-laden sputum, one of 
which was filled by his house-boy, the other by his 
coolie. Dr. Johansen also recently sent me six speci- 
mens of sputum, three of which contained ova in 
abundance ; of the ova-laden sputa one came from his 
hospital assistant, the other two from peasants living 
near Capsulan, a place about forty miles to the south- 
west of Tamsui. The facility with which these cases 
were found proves that the parasite must be very 
common about Tamsui ; and Mr. Graham's servants, 
who some time ago both visited Amoy, told me that 
haemoptysis, such as they themselves suffered from, 
was extremely common. Eegarding their acquaint- 
ances, one of them said that 20 or 30 per cent., the 
other that 15 per cent., spat blood. Possibly these 
are over-statements, but at all events they show that 
the disease is extremely prevalent. With regard to 
Central and South Formosa, I recollect very distinctly 
my surprise at the large number of cases of haemo- 
ptysis 1 used to meet with there, and have now little 
doubt that in distoma Ringeri we have the expla- 
nation. 

The geographical distribution of this parasite is 
peculiar, if it is the case, as seems probable, that it is 



142 DISTOMA RINGERI 

rare or entirely absent on the mainland of China. 
We have Professor Baelz's authority for its existence 
throughout Japan. I suspect, therefore, that there is 
something in the soil or geological structure common 
to Japan and Formosa, but not present on the neigh- 
bouring continent, that determines this apparent 
caprice in the distoma area ; and that this geological 
element, whatever it may be, is one necessary to the 
existence of the intermediary host. The distribution 
of similar parasites depends principally on the distri- 
bution of their intermediary hosts ; this fact can 
easily be understood. Both Japan and Formosa 
resemble each other in being volcanic, and are both 
members of that long string of volcanic islands that, 
stretching along the eastern coast of Asia, includes, 
besides these, the Loochoos, the Bashees, the Philip- 
pines, and a host of smaller islands. I believe that 
extended inquiry will show that distoma Ringeri 
exists in all of these. 

Endemic hsemoptysis can readily be diagnosed. 
There is a history of irregular intermitting haemo- 
ptysis associated with a slight cough, and, in the inter- 
vals of more active bleeding, the expectoration once 
or several times a day of small pellets of viscid, brown- 
ish mucus. Violent exercise is apt to produce pro- 
fuse haemorrhage, and irritation of the lung, in any 
way so as to induce coughing, causes the discharge 
either of quantities of blood or of the characteristic 
sputum. At the same time there are no objective 
symptoms of lung-disease, and the patient probably 
enjoys good general health. Examination of a small 
portion of the sputum with the microscope at once 
settles the diagnosis. I many times examined sputa 



AND ENDEMIC HEMOPTYSIS. 143 

from the two cases I had under close observation for 
a considerable time, and never failed to find abundance 
of ova, sometimes counting as many as 20 in a single 
field. 

The following are short notes of the two cases I 
refer to. I am told they are typical examples of the 
disease as found in Formosa. 

Case XXVII. — Heng, male, aged thirty-one ; resides in 
Sinhang, Tamsui, where he works as a house coolie. His 
family, he says, is quite healthy ; his mother, aged forty- 
four, and three brothers and four sisters are alive and well. 
His father died at fifty-eight of dropsy, and a sister died in 
childhood of small-pox. He himself is liable to ague. He was 
born in the town of Banka, and lived there till his eighteenth 
year ; then he hved in Kelung for two or three years ; 
afterwards he removed to Hobe, Tamsui, where his home has 
been for the last ten years. He has travelled about the north 
part of the island a good deal ; been in Tektcham two or 
three years ago ; and eight years ago accompanied some 
Japanese to Khilai, on the east coast, where he resided for 
upwards of a month. His blood-spitting dates from eleven 
years ago ; he was then working on the tea hills, with his father, 
near Banka. At first he noticed, when he breathed hard in 
carrying heavy burdens, that he coughed a Httle and brought 
up mucus mixed with blood ; from that time till now has 
spat blood more or less constantly ; some days none, other 
days a considerable quantity. Once when pulling in a boat 
about two years ago he suddenly brought up over a bowKul 
of pure blood ; but, as a rule, unless exerting himself violently, 
he only brings up a few drops mixed with the mucus. Some- 
times he does not spit for a few days, perhaps a month on 
end, and then the haemoptysis recurs, to last for one or two 
months. He has a slight cough, but on auscultation nothing 
much amiss can be detected. His thorax is very finely de- 
veloped. He says that he never exercised discretion about 
the water he drank, especially when young ; used to take it 
from river, well, paddy-field, or ditch, whichever lay most 



144 DISTOMA EINGERI 

convenient, and he sajs that nearly all North. Formosans are 
similarly indiscreet. 

Heng lived in my house from the 14th to the 
31st July, and during the whole of this time he 
could nearly always cough up blood or ova-laden 
mucus such as I have described. 

Case XXYIII. — Heo, male, aged twenty-two ; born and 
resident in Hobe, Tamsui ; a house-boy. Father and mother 
are both dead, both of them of some dropsical affection. 
Until he was eighteen years of age, enjoyed excellent health ; 
then, without any obvious cause, he began to spit blood, 
especially after making any very great exertion. During 
one year, many times each month, he continued to spit blood, 
about an ounce at a time. . He then got lighter work and 
the bleeding ceased, and has not recurred ; but he has a 
cough still, and almost every day expectorates pellets of 
tenacious, muddy, yellowish-brown mucus. Sometimes for 
several days, if the weather is fine and his work is Hght, 
there is no cough or spit ; but when the weather changes, or 
he has to exert himself, the cough and spit return. He com- 
plains of some pain about the left nipple, but the lungs 
appear healthy. His sputum is as described, and abundance 
of ova can be found in it. 

When examined with the microscope, the ova of 
distoma Eingeri are seen to be shaped very much 
after the fashion of a fowl's Q^g^ with the exception 
that a circular operculum about half the breadth of 
the Q^^ closes the broad end. On an average they 
measure about -gJ-Q-in. X g-^-in., but some specimens 
are slightly larger and others slightly smaller. There 
is considerable diversity likewise in shape, some being 
more globular than the majority, whilst others are 
more elongated and tapered towards the narrow end. 
Their colour, which, when blood is entirely absent, 



AND ENDEMIC HEMOPTYSIS. 145 

as is sometimes the case, imparts the characteristic 
brownish tinge to the sputum, is a dirty reddish 
brown, and appears to reside both in the shell and 
in the granular portion of its contents. The shell 
is without markings, and shows in double outline 
more especially when it has been fractured by pres- 
sure. When viewed with a high power the ovum 
is seen to contain one, two, or more well-defined, 
pale sarcode globules embedded in a structureless 
matrix containing abundance of irregularly disposed 
dark granular matter. Usually one of these sarcode 
globules is brighter and better defined than the rest. 
!By careful focussing they are seen to be made up 
of very minute granules in a state of active molecular 
movement. Pressure ruptures the shell at the oper- 
cular end, forcing out the contents, which resolve 
themselves into innumerable globules of all sizes, 
from fine microscopic granules to large bodies sifoo'i^- 
in diameter. The smaller particles exhibit very active 
molecular movements, and tend after a time to coalesce 
round the larger. No trace of a differentiated em- 
bryo can be distinguished. Once or twice I have 
seen attempts at yelk cleavage, a dozen or more 
elongated cell-like bodies with a bright nucleus in 
each occupying the whole of the interior of the egg ; 
but never anything more advanced than this. 

It is evident, therefore, that some time must 
elapse before an embryo can be sufficiently deve- 
loped to start on the independent existence which 
has been found to be the first step in development 
in those distoms whose early life history has been 
studied. Eeflecting that the ova are deposited in 
the sputum, that this affords probably their only 

L 



146 DISTOMA RINGERI 

means of escape from the human lungs, and that they 
are placed in it with a purpose, I concluded that by 
following out the destinies of a sputum I should 
probably be set on the right track for working out 
the first stage at least of the history of distoma 
Ringeri. 

When sputum is cast on the ground one of three 
things may happen : first, it may be eaten by earth- 
worms, molluscs, or other creatures ; second, it may 
dry up and mix with the soil, the solid parts of it being, 
perhaps, afterwards blown about as dust ; third, it may 
be washed and carried away by rain into well, ditch, 
pond, or river. I considered that if in any of these 
ways the ova are borne to suitable incubating media, the 
last is the most likely to favour the development of the 
distoma, and most in consonance with what happens 
in the case of better-known species. Accordingly, 
I determined to imitate nature as far as I could in 
this direction, on the supposition that rain or water 
was the first agency that operated on the ova. 

I procured two supplies of sputum from the man 
Heng ; one lot I placed, without admixture of any sort, 
in a wineglass, and covered it up, keeping it for 
comj)arison and future experiment ; the other lot, 
measuring about one ounce, and containing many 
thousands of ova, I shook up with about an equal 
quantity of filtered well-water until the mucus, blood, 
and ova were thoroughly diffused. This was divided 
into about equal portions between six wineglasses, 
and water sufficient to fill the glass was added to 
each. These were numbered 1, 2, 3, 4, 5, 6, and 
placed under a glass shade in a room where, during 
the subsequent steps of the experiment, the thermo- 



AND ENDEMIC HEMOPTYSIS. 147 

meter ranged between 80° and 94° F. Next day 
JSTo. 1 was not disturbed, but all water, exce2:)t the 
drachm or two at the bottom of each glass, containing 
the sediment and ova, was removed by means of a 
syringe from 2, 3, 4, 5, and G, and fresh water added. 
On the following day 1 and 2 were not disturbed, but 
3, 4, 6, and 6 were again watered, and so on. Thus 
in No. 1 the ova were washed once, in No. 2 twice, in 
No. 3 thrice, in No. 4 four times, in No. 5 five 
times, in No. 6 six times, the washings taking place 
at intervals of twenty-four hours. 

My notes of observations show that no develop- 
ment occurred in the unwashed ova ; that it was 
delayed in No. 1, where only one washing had 
been performed ; that it advanced steadily with- 
out much notable difference in 2, 3, 4, 5, 6, 
until at the end of from six weeks to two months 
the majority of the ova produced active ciliated 
embryos. A small quantity of sediment from one 
or more of the glasses was removed with a pipette 
daily, or every second day, and examined under the 
microscope. Ova were always easily found. For the 
most part they were entangled in little flakes of 
miscellaneous dehrisj but from this they could easily 
be separated. Notes were made of the various 
changes as far as they could be detected ; but for 
the first few weeks, on account of the dark, granular 
character of the contents, it is difficult to say precisely 
what the different steps were that led up to the 
formation of the mature embryo. Great molecular 
activity can be detected in the paler globules for some 
time ; then these lose their distinctness, large oil 
globules appear about the periphery of the yelk, and 



148 DISTOMA RINGERI 

a paler mass shows in the centre. In time the latter 
contracts, leaving the shell by a considerable space, 
Langnid movements ensue in it ; these become more 
active ; a ciliated epithelium is developed on its 
surface, and an indentation at the opercular end 
indicates the presence of a mouth of some sort. 

On the twenty-sixth day of incubation I note : — • 
Examined some sediment from No. 3, and in it found 
an ovum of characteristic shape and colour, with an 
embryo in it possessing considerable activity and 
plastic power. It moved vigorously in the shell, and 
altered from time to time the shape of its body, which, 
for the most part, was heart-shaped, a distinct depres- 
sion existing at the opercular end. Contents of the 
body granular. 'No vessel visible. No cilia visible 
when in ovo, but on crushing the egg the ruptured 
embryo escapes and its collapsed integument is then 
seen to be covered by long cilia, which keep in 
active movement for about one minute. Examined 
No. 4, and found several ova Avith active embryos 
of the same character. Also N"o. 1, but in it there 
appeared to be no advance in development. 

On the twenty-eighth day I note : — In all the 
glasses, except No. 1, the ova contained ciliated 
embryos. If carefully expressed, the embryo re- 
tains its activity for eight or ten minutes after its 
escape. It rushes off from the egg a globular, 
ciliated, rotating ball; as movement subsides the 
body elongates, and a ciliated ejDidermis is seen 
to extend from the tail as far forward as the anterior 
third or shoulder of the animal. The anterior part 
is naked, and at its apex is provided with a papilla 
or beak. 



AND ENDEMIC HEMOPTYSIS. 149 

The body of the animal evidently lies free in the 
shell, the cilia motionless at this stage and directed 
backwards. If we watch the anterior part or head, 
which is always directed to the operculum, and for 
the most part closely applied to it, it is manifest that 
this is fixed in some way. By careful examination of 
ova at a later stage of development, I have satisfied 
myself that this is effected by an involution of the 
delicate membrane lining the shell, which here be- 
comes continuous with the ciliated epidermis of the 
body ; thus the neck is surrounded by a sort of collar, 
which keeps it a fixed point. The movements of the 
animal, during the last few days of its residence in the 
egg, appear to be directed to rupturing this connection, 
for the head is first turned forcibly to one side, then 
to another, expanded, contracted, and jerked about, as 
if the little thing were annoyed and irritated by the 
collar restraining it. When this has been ruptured 
the embryo moves about in the shell, trying in an 
excited sort of way to escape, the cilia vibrating 
rapidly. Frequently, failing to force the operculum 
open, it turns completely round and energetically 
butts the opposite pole of the ovum with its head. 
After a time it succeeds in opening the operculum, 
which is either carried completely off, and may be 
found lying at some distance, or is thrown back as if 
on a hinge. 

If we rupture an ovum very carefully a week or 
two after the appearance of the cilia, and are success- 
ful in extruding the little animal without crushing its 
delicate tissues, it will move away from the shell a 
short distance, its body elongating and contracting, 
and the cilia playing rapidly for a few minutes. 



150 DISTOMA RINGERI 

Gradually all movements will cease, the body passing 
from heart-shape to sj)ade-shape, the handle of the 
spade being represented by a minute papilla with a 
very fine canal, apparently opening at its apex. Now it 
may be distinctly seen that the ciliated epidermis does 
not cover the fore part of the body, only the posterior 
two-thirds, extending as far forward as the rounding 
in of the shoulder ; also that the epidermis is in plates, 
one covering the tapered posterior end, and two other 
indistinct lines in advance of this indicating that 
altogether there are three or four such plates or 
bands. Soon after extrusion the homogeneous or finely- 
granular contents present larger globules containing 
actively moving granules, and as the feeble con- 
tractions of the body and ciliary motions cease, these 
granular globules increase in number, until finally the 
entire mass is made up of minute dancing micrococcus- 
like particles. Then the epidermic plates roll up, 
leaving the body quite naked, the cilia fade from 
view, and finally an amorphous mass is all that 
remains. 

If, however, we rupture the ovum at a later stage 
of development, or if our observations are made just 
when the embryo has squeezed its plastic body through 
the natural opening, the behaviour of the embryo is 
somewhat different. First, the cilia are seen to start 
into rapid motion, and then, after a preliminary pause, 
to rupture and separate itself from the lining mem- 
brane of the shell which is sometimes forced out 
entire along with it, or, apparently to consider what 
has happened, the animal rushes ofit at great speed, 
gyrating about after the manner of certain infusoria. 
From time to time it pauses, contracting itself into a 



AND ENDEMIC HiEMOPTYSIS. 151 

perfect disc or globe, rotating rapidly on its axis, first 
in one direction, then in another. Anon, it dashes off 
to a distant part of the slide, exhibiting in its course 
many diversities of form. When going at high speed 
the body is much elongated ; at a less speed oval, or 
fiddle-shaped, or square ; but at no time is the beak 
or naked shoulder protruded as long as the animal is 
alive and active, a slight depression on the ciliated 
surface alone indicating where these are retracted. 
Beneath the epidermis is a thick contractile layer ; 
the interior apj)ears to be fluid or a soft jelly, holding 
minute granules in suspension, and sometimes a larger 
bright point can be detected. No vessel of any sort 
can be traced. I do not know how long the animal 
preserves this active ciliated form. I have kept one 
alive in a glass cell for over twenty-four hours (Plates 

yiii., IX.), 

Such, briefly, is the history of the first step in the 
development of distoma Ringeri. The ova are laid 
into the bronchial mucus ; in the sputum they are 
cast on the ground ; by rain, or other means, they are 
carried to stagnant water; they sink to the bottom; 
in the course of six weeks or two months ciliated 
embryos are developed ; when mature these force 
theii' opercula, and swim free in the water. What the 
next stage may be can only be conjectui'ed. Doubt- 
less, they enter the body of some fresh-water animal 
to undergo further metamorphoses. Perhaps this 
animal is eaten by man, or, possibly, the parasites once 
more obtain their freedom, and, while still in the 
water, are swallowed, and thus obtain an opportunity 
of gaining access to the human lungs, their final 
destiny. 



152 DISTOMA RINGEEI 

I have not spoken yet of the fate of the unwashed 
ova. The glass containing them was not disturbed 
for abont three weeks. At the end of this time the 
sputum had decomposed, stank abominably, and had 
settled into two layers ; one upper, more or less clear, 
and a lower, turbid and dark brown. On sampling 
the lower layer, into which the ova might be supposed 
to have gravitated, but few specimens could be found. 
These, however, were, as far as I could judge, in no 
way different from perfectly fresh specimens. The 
sputum was then washed repeatedly with fresh water. 
But, although in the sediment ova were numerous, no 
decided advance in development could be detected ; on 
the contrary, in many, signs of decomposition were 
apparent at the end of two months. In others, again, 
the characteristic globules of sarcode could still be 
distinguished. Thus it would appear that unless the 
ova are freed from mucus and have access to fresh 
water within a short time of their birth, they perish. 
If, however, water is supplied to them soon after they 
leave the lungs, though in limited amount, as was 
done in the case of glass ISTo. 1, they do not rot, but 
retain their vitality, proceeding slowly in develop- 
ment. In the case of the ova in this glass the em- 
bryos were not differentiated till about the fortieth day. 
It is evident, therefore, that the ova must be brought 
into contact with water, and that this is the medium 
through which the parasite, and the disease it produces, 
pass from one human lung to another. In the history 
of this parasite we have another argument, if such is 
needed at the present day, for a pure water supply. 
Not many months ago there were few who would not 
have laughed at the idea that blood-spitting could be 



AND ENDEMIC IIvEMOPTYSIS. lOO 

produced by a draught of dirty water. Now this 
connectiou cau be demonstrated. How many more 
diseases acknowledge impure water as one of the 
most important factors in their etiology, time and the 
advance of science will show. This matter of dis- 
toma Eingeri and endemic hasmoptysis may have 
little practical interest for any but some 40,000,000 
or 50,000,000 of Asiatics and the few hundreds of 
Europeans who live among them, but it is a valuable 
text for the advanced sanitarians of Europe to work 
on and preach from ; to show, that to-morrow some 
new fact may disclose unsuspected connections between 
disease and uncleanliness. 

By these observations the search for the inter- 
mediary host is limited to a comparatively small group 
of animals. It must be an inhabitant of fresh water ; 
it is common to Japan and Formosa ; it does not in- 
habit or is rare on the mainland of China, — at least 
that part of it near Amoy. The latter circumstance 
has precluded me from pursuing the investigation 
further, but I trust it will be taken up and success- 
fully completed by some one residing in Formosa or 
Japan, who, being in the midst of the disease, must 
enjoy ample opportunity. The limitation of the field 
in which investigation need be made must simplify 
the search ; but that it will be a short and easy one 
does not follow. The history of the liver fluke, the 
cause of so much disease in sheep, is not yet com- 
plete, notwithstanding the great inducements and 
facilities offered to its investigators in Europe and 
elsewhere.* 

* Since this was written, the beautiful researches of 
Thomas on the metamorphosis of the liver fluke in LimnmM 



154 DISTOMA EINGERI 

On discovering the cause of endemic haemoptysis, 
the first thought that suggests itself is the possibility 
of curing it. Could the parasite be killed, the disease 
would be arrested. An important point bearing on 
this question has yet to be ascertained, and that is the 
exact site of the parasite in the lungs. Is it free in 
the bronchi, or is it jammed into the branches of the 
pulmonary artery ? If the former, the parasite may 
be dislodged ; if the latter, the prospect of cure must 
be very small indeed. An autopsy is necessary to 
settle this point, and I trust our confreres in Japan 
will bear this point in mind when they get the ojDpor- 
tunity. The exact position of the mature parasite 
could easily be ascertained by microscopical exami- 
nation of bronchial mucus ; the appearance of ova in a 
particular tube would show that the animal is to be 
found by following up that lead.* 

Proceeding on the assumption that the parasite had 
its habitat in the bronchi, I made several attempts in 
the two cases I have given to kill or dislodge it. I 
caused the patients to inhale the spray of solutions of 
various drugs atomized by a Lister's steam apparatus. 
In this way the tincture and infusion of quassia, the 
infusion of kousso, solutions of turpentine and san- 
tonine in spirits of wine were introduced into the 
lungs. In addition to these the man Heng inhaled 

truneatulus have been published, and an important blank in 
the life-history of a destructive parasite filled in (see " The 
Quarterly Journal of Microscopical Science," January, 1833). 
* For some very valuable observations by Dr. Cobbold on 
the lung flukes, see the reports in the medical journals of a 
discussion on the subject at the meeting of the Medical 
Society, March, 1883. 



AND ENDEMIC HEMOPTYSIS. 155 

the vapour of burning sul])liur. Inhalation was 
practised twice daily for a week in one instance, and 
for a fortnight in the other. Certainly before these 
men passed from under my personal observation they 
were improved so far as cough and expectoration were 
concerned, but in both instances a small amount of 
ova-laden sputum could still be procured by irritating 
the lungs and inducing cough ; they returned to 
Tamsui before I could be sure that the cm^e was com- 
plete. In reply to my inquiries, Mr. Graham wrote 
me lately that Heng still spits small quantities of 
blood at long intervals, but that Heo has now no 
cough and can no longer bring up distoma mucus. 
He, possibly, is cured.* 

I am sorry I have not been able to carry further 
these experiments in treatment. I would not allude 
to them now had I much prospect of being able to 
extend them. I mention them only in the hope that 
others, with opportunities better than those I enjoy, 
will pursue the inquiry in this very practical 
direction. 

Our knowledge of the history of the ovum, and 
the medium in which it is developed, indicates the 
direction which effort at prevention should take. But 

* I had an opportunity of examining Heo three months 
after the attempts at cure above described. He said he was 
quite well, that he had lost his cough, had spat neither blood 
nor mucus, and that he regarded himself as cured. I caused 
him to inhale irritating substances, and thus forced him to 
cough violently, but he failed to bring up any trace of dis- 
toma sputum. He told me that my other patient, Heng, 
still spat blood ; and he also brought me three specimens of 
ova-laden sputum from three of his friends in Tamsui. 



156 DISTOMA EINGEEI AND ENDEMIC HEMOPTYSIS. 

1 fear our knowledge in this instaDce is a little in 
advance of any practice we may look for in a For- 
mosan. Europeans who happen to be stationed in 
Formosa, or who may be travelling in the island, will 
understand from these remarks the necessity for extra 
caution with regard to drinking water. They should 
never neglect to boil or filter it when the least 
suspicion is entertained about its purity. A little 
neglect in this matter may be paid for with a chronic 
heemoptysis. 



CHAPTEE VIII. 

LIGULA MANSONI. 

"While making a post-mortem examination of a 
Chinaman on September 21st, 1881, I encountered in 
the abdomen a number of animals belonging to an 
order of jDarasites which have not hitherto been 
found infesting the human subject, although common 
enough in certain of the lower animals. The speci- 
mens I brought to England and submitted them to 
Dr. Cobbold, who has pronounced the species to be 
new to science, and has named it ligiila Mcmsoni. 
I cannot say if this parasite has any pathological 
importance. I mention the matter here in the hope 
that attention having been directed to it, other 
observers, with better opportunities for post-mortem 
examinations in Orientals than I enjoy, may be 
induced to look for this new parasite and work the 
matter out. 

In the post-mortem referred to the parasites were 
found in the loose areolar tissue behind the kidneys, 
and in the subperitoneal areolar tissue in the flanks 
and iliac fossae. One specimen was found free in the 
right pleural cavity. They were twelve in number. 
Some were coiled up in a loose knot, others again 
were slightly extended. They could be seen through 



168 LIGULA MANSONI. 

the peritoneum, and when this was incised were 
easily dragged out of the loose subperitoneal fascia. 
In colour they were dead white, and when extended 
at full length measured twelve to fourteen inches 
in length, by one-eighth of an inch in breadth, and 
one-sixtieth in thickness ; the two extremities were 
rounded off and rather thicker than the rest of the 
body. To the naked eye there were no transverse or 
other markings visible, although the general appear- 
ance of the animal, its shape, colour, and languid 
vermicular-like movements forcibly reminded one of 
a tapeworm. Unfortunately, I had little leisure at the 
time for a careful microscopic examination, but this 
much I made out, that one extremity was lipped, and 
the other had a short longitudinal slit in it. The 
whole of the body was occupied by a vast number 
of clear spherical bodies, each having a double or 
treble outline and distinct nucleus; these were held 
together by a loose fibrous matrix and very thin 
transversely striated integument.. Slight pressure 
caused the matrix and integument to split up longi- 
tudinally and rupture transversely. I made out no 
trace of alimentary or generative organs. 

Specimens of these parasites were shown at the 
Linnsean Society, and at the same time a very in- 
teresting paper on the subject of "Ligulosis" was 
read by Dr. Cobbold. 

The following are my notes of the case and post- 
mortem examination in which the parasites were 
found. The case is further of interest as illustrating 
some of the points I have already discussed when 
treating of filar ia sanguinis Jiominis. 

Case XXIX. Lympk-scrotum and ele^jhantiasis scroti com- 



LIGULA MANSONI. 159 

hined; profuse discharge of Jym'ph ; groat dehilitj/ ; filarice in 
Mood and lymph ; operation ; death ; post-mortem examination ; 
ligula Mansoni in abdomen. — Tchhai, aged thirty-four; a 
cotton carder from Tchin Kang, Tchhiali thoh. No particular 
family disease ; no elephantiasis in his village. 

He stated that his scrotal trouble began, when he was twenty- 
six years of age, with an attack of fever and inflammation 
ending in abscess. After the first attack fever and inflam- 
mation of the scrotum frequently recurred. Six years ago 
scrotal discharges appeared for the first time ; then the scrotum 
was much larger than at present and very tense. About ten 
months ago he had a long series of regular ague attacks, first 
quotidian, then tertian, and finally quartan in character ; 
altogether he was ill with this fever for seven months. He 
suffered from cough and anorexia. Latterly, for about a 
month, the discharge from the scrotum has been nearly con- 
stant, running him down to a state of excessive debility. 

September 2nd, 1881. — The scrotum is larger than a man's 
head, and the penis is bm-ied in it. Of the groin-glands the 
femoral, especially those on the left side, are most affected ; 
they are large and varicose. Only one or two on the right 
side are involved. The greater part of the scrotal tumour 
feels and looks like an ordinary elephantiasis, but on the 
right, and more especially on the left side of the mass, there 
are groups of large tense vesicles — the group on the left side 
occupying an area the size of the palm of the hand. Also, 
on the upper part of the tumom-, about two inches from the 
orifice of the prepuce, there is a long dilated lymphatic about 
an eighth of an inch in diameter. Lymph is constantly escap- 
ing in a fine stream from a vesicle on the right side of the 
scrotum, and from any vesicle that is handled at all roughly. 
Several pounds of lymph must have escaped to-day. It is 
white, like watery milk, coagulates, and contains filarise. 
Several were found in a short examination of lymph drawn 
at eleven a.m. to-day. Blood drawn at 6.30 p.m. contains 
filarise. There is no elephantiasis of the legs, nor is there any 
history of chyluria. 

September 3rd. — Although the man was in very bad health, 
and in addition to his other troubles had symptoms of stric- 



160 LIGULA MANSONI. 

ture of the oesophagus,* his only chance appeared to he from 
an operation on his scrotum. The profuse and uninterrupted 
lymphorrhagia would certainly kill him in a very few days. 
I accordingly removed the scrotum to-day. It weighed over 
three pounds, and exhibited the usual structure of a lympho- 
elephantoid tumour. A hernia on the right side, firmly 
adherent to the bottom of the scrotum, had to be dealt with, 
and gave some trouble in d^'ssecting up. Dilated lymphatics 
in the upper and outer angles of the wound discharged lymph 
profusely and had to be ligatured. 

September 21st. — The case did well for some time after 
operation. There was no recurrence of the lymphorrhagia, 
but the difficulty of swallowing from the strictured oesophagus 
increased, and made the administration of a sufficiency of 
nourishment impossible. Dysentery then set in and he died 
this morning. At the time of his death, the wound, though 
indolent, was quite clean, and in no Avay responsible for the 
fatal termination. 

Post-mortem Examination. — Body very thin ; feet oedema- 
tous. Abdomen — bladder too full ; whole of the large in- 
testine covered with ulcerations from ileo-coecal valve to anus; 
no adhesions or signs of peritonitis; two lumbrici in the 
stomach, and about a dozen in the small intestine ; the para- 
sites I have already described under the peritoneum. Thorax 
— normal except the oesophagus ; this, where the left bronchus 
passes over it, was thickened and adherent to the bronchus ; 
the lumen of the tube was so constricted that it could not be 
traversed by the little finger, and on slitting it up a thicken- 
ing and ulceration occupied a complete segment of the tube 
for about an inch and a half at the situation indicated ; I could 
not pronounce the thickening to be cancerous ; the ulceration 
on the mucous siu-face was very ragged and irregular, and 
one little hole extended through to the interior of the left 
bronchus. In the left bronchus were two full-grown lumbrici, 

* Strictm'e of the oesophagus is a remarkably common 
disease in Amoy. I have never been able to satisfy myself 
as to the cause of this fi-equency. I do not think that the 
strictures are malignant or traumatic. 



LIGULA MANSONI. 161 

which doubtless had crept up from the stomach after death 
and found their way to the lungs through the ulceration in 
the o3sophagus. The lymphatics of the groin over the 
saplienous opening, especially the left, were finn, but not 
hard. They gave the idea that the outer part of the gland 
had at one time been distended, but had collapsed enclosing 
a firm nucleus. Tlie lumbar glands were also enlarged. I 
examined blood from the lungs and found in it a few filarifie ; 
also blood from the spleen, and this too contained a few filarise ; 
lymph expressed from the left groin-glands contained filarise 
in considerable abundance. 

I regret I was unable to make a more minute examination 
of the lymphatics. 



CHAPTEK IX. 

TINEA TMBEICATA, AN UNDESCRIBED SPECIES OF BODY 
KINGWOEM.* 

Dermatologists pretty well agree in their descriptions 
of the various forms of epiphytic skin disease, and in 
the characters of the vegetable parasites with which 
they are associated. Favus, tinea tonsurans, tinea 
decalvans, chloasma, are distinct diseases, and are 
generally recognized as such. This unanimity, how- 
ever, does not obtain in the case of tinea circinata^ 
or ringworm of the body, some authorities teaching 
that there are several species of tinea included 
under this name, while others affirm that there 
is but one disease, and one species of fungus 
j)roducing the different modifications. Dr. Tilbury 
Fox is one of the most recent writers advocating this 
latter view. In his work on skin diseases he is very 
decided in his assertions. He says, referring to this 
subject, " It will be seen that I include a number of 
diseases hitherto regarded as distinct from tinea 
circinata under that head. Of the correctness of this 
step I have no shadow of doubt, and it really saves a 
vast addition to the vocabulary of the dermatologist." 

* Reprinted from the " Customs Medical Reports," 
No. 14. 



TINEA IMBRICATA. 163 

Under one head he brings, besides the typical form of 
tinea circinata^ all what he calls its uncommon phases, 
" such as general parasitic tinea, parasitic eczema, 
Eurmese. ringworm, eczema marginatum, Malabar 
itch, Chinese itch, etc.," and these varieties of the 
disease he attributes to the influence of diversity of 
climate, clothing, constitution, and part of the body 
affected. 

While agreeing with Dr. Tilbury Fox in the 
desirability of simplifying so complicated a subject, 
with all deference to his high authority I take the 
liberty of asserting that his generalization is too 
sweeping, and that there are at least two distinct 
and well-marked species of body ringworm. I agree 
with him thus far in considering that the names he 
enumerates do not ahuays^ or generally, represent 
different species of disease ; but when he maintains 
that there is only one species, he goes too far, and, I 
believe, is mistaken. It seems strange that one so 
practised in observation should fall into this error. I 
can only account for it by supposing that he and 
those Avhose opinions he represents have never seen a 
case of the disease I propose to describe under the 
name of tinea imhricata^ and that a careful description 
of its characteristics is not to be found in medical 
literature. In the following remarks I will endeavour, 
by a detailed account of a case of tinea imhricata and 
another of tinea cireinata, to supply this description, 
and bring out the characteristics of the two diseases 
by their contrast ; and, afterwards, I hope to show by 
a description of the microscopic appearances of their 
respective fungi, and the results of experiments in 
inoculation, that the difference is not only in clinical 

M 2 



164 TINEA IMBRICATA. 

characters brought about by peculiarities of circum- 
stance, but actually in species, and is everywhere and 
in all circumstances constantly maintained. 

Details of a Case of Tinea Imhricata and of a Case of 
Tinea Circinata. 

Case I. Tinea Imhricata. — Liam, male, aged forty-five ; 
a rice grinder ; native of, and resident in, Amoy. He 
is well nourished, muscular, and in excellent general 
health. Twenty years ago he emigrated to the Straits 
Settlements, where he worked in a sago factory, hut returned 
to Amoy after an absence of only three years. He came 
back in consequence of the eruption of the skin disease 
he now suffers from, his friends having told him it would 
disappear in the cooler and drier climate of China. He was 
in the Straits but a few weeks when the inner surface of his 
right thigh was attacked by the disease, which, in the course 
of three years and a half, spread over nearly the whole of 
his body. At the sago factory there was a Cantonese who 
had the disease. This man's towel he used to wipe his body 
with, and to this circumstance he attributes his infection. 
There has been no remission all these twenty years ; his skin 
has all along had the same appearance. Duiing the winter, 
perhaps, the itching which troubles him so much in warm, 
damp weather, is mitigated. 

The extent of the disease is most easily described by 
enumerating the parts not involved. These are : 1. A 
symmetrical patch of sound skin, extending in front from 
over trochanter major to trochanter major; on an average 
this patch is about four inches broad ; in the middle of the 
body it expands slightly and includes the genitals. 2. An 
oval patch in the middle line over the lower lumbar vertebrae ; 
it is about the shape and size of the palm of the hand, its 
long diameter lying vertically. 3. A symmetrical patch in 
front of the chest, including both nipples and stretching from 
armpit to armpit, the skin of the walls of which, both 
brachial and thoracic, is quite healthy. This patch measures 
over the sternum about six inches in breadth. 4. The 



TINEA IMBRICATA. 165 

whole of the hairy scalp, with the exception of that over the 
occiput, the disease on which is continuous with that of the 
neck. These foiu' patches of sound skin are shaped and 
arranged symmetrically ; but, 5, a long irregular surface on 
the front of the left leg has nothing coiTCsponding to it 
on the right side. With the exception of the parts enumer- 
ated the whole of the rest of the skin is implicated. 

It would be difficult to give a description applicable to the 
disease as it is seen in all parts of the body, but if I select 
one spot some idea of what I might call the plan of the 
disease may be conveyed. 

The patch selected is situated just above the right 
nipple. On the surface of this the epidermis is arranged 
in a series of wavy lines, lying parallel to each other, 
and having a more or less concentric arrangement in relation 
to an imaginary point situated somewhere about the tip 
of the right shoulder. It is very like the ringed appear- 
ance in a cross-cut log of wood. On closer examination, this 
effect is found to be produced by an undermining of the 
epidermis, giving rise to long flakes, about one- eighth of an 
inch in breadth, the free edge of the scale being directed 
towards the centre of the circle, the convexity remaining still 
firmly attached. If the hand is passed over the surface from 
the circumference towards the centre of the circles, the scales 
are smoothed down ; if in the reverse direction, they are 
raised up, and stand out prominently, defining the wavy 
outline of the rings very distinctly. If we attempt to detach 
the scale it is found to be firmly adherent at the outer edge ; 
but by using a little force it can be peeled ofi", the flake 
becoming thinner, softer, and more delicate the further we 
proceed from its original attachment, until it is completely 
separated. If the forceps is carefully used, two or more 
inches in length of epidermis can thus in some places be 
separated in a continuous, unbroken ribbon. Just under the 
free edge of the scale, the skin is lighter in colour than 
between it and the preceding or succeeding rings. The rings 
are about one-eighth to one-quarter of an inch apart, so that 
thirty can be counted between one corner of the square and 
the other. Some are quite regular in their outline over a 



166 TINEA IMBRICATA. 

length of five or six inclies ; others, again, are interrupted at 
intervals, and more or less irregularly convoluted ; but there 
is no spot an inch square within the area of the disease un- 
occupied by these scaly rings. 

On the soft and protected skin of the thorax and abdomen 
the disease and its characteristic features are seen in their 
greatest perfection. On the back and shoulders the flakes of 
loosened epidermis, being seldom disturbed by scratching or 
friction, have acquired greater dimensions, but from their 
size and the irregular way in which they have been shed, 
they more or less conceal the ringed pattern so evident in 
front. The arms and legs, feet, hands, and face being 
subject to much friction have assumed a rough, reddish, 
furfuraceous appearance, with the wavy outline of the rings 
only visible in places. The hair of the eyebrows and occiput 
seems quite healthy, growing strong and glossy through the 
diseased epidermis. Though rough to the touch from the 
desquamation, there seems to be no thickening or effusion 
into the corium, notwithstanding the length of time the 
parts have been affected. 

In this case, as observed at present, the line of demarcation 
between the perfectly sound and the diseased skin is not very 
abruptly marked. It looks as if the disease endeavoured at 
times to push on to, and establish itself in, the sound skin, 
but finding the ground unsuitable, released its hold, leaving 
little outposts of spots and lines at intervals along the ground 
it has been compelled to abandon. 

Over the abdomen, the rings have advanced from right to 
left, the free borders of the scales being du^ected to the right ; 
over the thorax on both sides, diagonally from above down- 
wards and without inwards ; over the back from a point 
between the shoulder-blades. 

Another point deserving of particular notice is the existence 
of symmetrically arranged patches of leucoderma on which 
there is no scaling or rings. Such patches are to be seen on 
the anterior surfaces of the wrists and forearms ; and still 
more markedly on the upper, anterior, and inner surfaces of 
the thighs. The disease has been in existence longest in these 
locahties. In the leucodermic patches the loss of colour, 



TINEA IMBRICATA. 107 

though extending over a considerable area, is not in one large 
continuous patch ; but white spots, an inch or more in* 
diameter, are mixed with spots of the natural coloiu' of the 
skin, giving the places mentioned a piebald appearance. 

During all the years this man has lived in Amoy, he is not 
aware of having communicated his disease to any one. 

Case II. Tinea Circinata. — Tchok, male, aged nineteen ; 
came to hospital suffering from general debility and ring- 
worm. 

The characters of tinea circinata are well known. A 
minute description of them is therefore unnecessary. In 
giving this case I will merely mention the principal and 
diagnostic features, to insure its being recognized as the 
disease in question. 

On his face, and nowhere else, is a well-marked ringworm. 
It has been out for one month only, and spread from a spot 
on the right side of the nose. The ring is incomplete on the 
right cheek, and is broken in several other places, once by the 
right eye, again by the mouth, and again by the left ala nasi. 
On an average, it is about a quarter of an inch in breadth ; it 
is slightly but distinctly elevated, of a dark red colouj', sctu-fy 
and obscurely vesiculated at places, and is very itchy. The 
margin is more abrupt at the spreading, shading off at the 
receding edge ; and though there is a tendency at the convex 
border to undermining of the epidermis, the scales so pro- 
duced are very minute, not in any place measuring more than 
^-in. X -^V-in. There is no attempt whatever at reproduc- 
tion of a ring in the skin already travelled over, which is 
quite natural in colour and texture. Under the microscope 
mycelium and spores of trichophyton are to be detected in 
scrapings from the ring. 

Trichophyton Tonsurans and the Fungus of Tinea 
Imbricata. 

The microscopic appearances of the fuDgus of tinea 
imh-icata, although in many respects closely resem- 
bling those of the fungus of tinea circinata (tricho- 



168 TINEA IMBRICATA. 

phyton tonsurans), are yet sufficiently distinctive to 
rentier the diagnosis of the disease by the microscope 
alone quite a simple affair. In the first place, it is 
often no easy matter to find fungus elements in tinea 
circinata^ and several slides may have to be examined 
before a fragment of mycelium, not to mention a chain 
of conidia, is found. But in the case of tinea imhi- 
cata^ one has only to raise any scale on the diseased 
surface, and place it under the microscope, to see 
fungus elements in enormous abundance. In every 
field are hundreds of conidia, arranged in chains, 
crossing and re-crossing each other, and mixed with a 
fair proportion of mycelia ; and with a little alteration 
of the focus one can see that there is not one, but 
several layers of this elaborate network. This con- 
trast in the quantity of fungus in any given specimen 
is most remarkable. 

Another point of contrast is in the position the 
fungus occupies in the skin. There can be no doubt 
about this in tinea wibricata ; it is always in the 
lowest layers of the scale of epidermis. From the 
size of the scale, which can be raised and laid on the 
slide smoothly and accurately, this is easily deter- 
mined. In the case of the fungus of tinea circinata, 
we cannot be so certain from microscopic evidence 
aJone of its jDOsition; but the mycelial threads seem 
to spring from deep in the skin, and wiud in and out 
amongst the superjacent layers of epidermis. The 
seat of tinea imbricata is undoubtedly in the non- 
vascular rete Malpighii, or deeper layers of the 
epidermis ; of tinea circinata, probably in or on the 
surface of the vascular corium and its hair follicles ; 
hence the small amount of irritation and infiamma- 



TINEA. IMBEICATA. 169 

tory change excited by the former, and the thicken- 
ing, induration, and red raised ring of the latter. 

Additional proof that the rote Malpighii supplies 
the pabulum on which the fungus of tinea imhricata 
lives, is afforded by the absence of colour in the skin 
just travelled over by the rings of advancing disease, 
and by the frequent occurrence of leucodermic patches 
in those parts which have been longest affected, and 
the subsidence of the disease where the skin fails to 
reproduce its pigment layer. 

Fungus of Tinea Imhricata (see Plate X.). 

Conidia^ — generally oval, rarely circular, often 
irregular, measuring from ro oo~o"i^- ^^ Woo'i^- i^ 
diameter, arranged in single rows, or long, often- 
branching chains. They appear to be formed in two 
ways, either by division of previously existing 
conidia, or by segmentation of mycelium. Where 
the latter has recently been effected, the conidia are 
more rectangular, of a darker colour, and often con- 
tain reddish-brown granules ; otherwise the conidia 
are colourless, without markedly granular contents, 
and of a rounded contour. If a chain of conidia is 
traced to its termination, this is usually found to con- 
sist of a longer and larger spore, in some instances 
exhibiting a transverse constriction, as if dividing. 
In an ordinary specimen these chains of conidia are 
much more numerous than the accompanying mycelial 
threads. 

Mycelium varies in breadth from a very minute 
thread up to -g-Q^-Q-in. It appears to be of two 
sorts, a paler and a darker, though intermediate 
forms can usually be found also. The paler variety 



370 TINEA IMBRICATA. 

is less sharp iu outline, and from its rounded appear- 
ance resembles more than does the other the struc- 
ture of the perfect couidia ; it branches frequently, is 
interrupted irregularly by articulations and delicate 
transyerse septa, and frequently terminates or arises 
in a chain of conidia. The darker variety is more 
tape-like in its appearance, and is recognized by its 
delicate but sharply-defined border, and the numerous 
granules of dark, reddish- brown material it contains. 
This latter form is also frequently branched, and little 
protuberances are attached to it at intervals ; it is 
much articulated in places, and terminates in a bulb- 
ous extremity or in a chain of conidia. The colour 
granules tend to run together when the specimen has 
been immersed some time in dilute liquor potassa3. 
Both forms of mycelium vary much in diameter, and 
the threads are but slightly bulged and only at long 
intervals. 

Stroma. — This I have not recognized with certaintj^ 
in recent preparations ; but if the scales are kept for 
several weeks in a diy bottle, and then examined, it 
will be found that the conidia have nearly entirely 
disajDpeared, their place being taken by large, articu- 
lating, much-branched mycelial threads and patches 
of what I believe to be stroma. This latter is made 
up of innumerable exceedingly minute globular cells, 
heaped together without any definite arrangement. 

As in all cases of epiphytic skin disease, bacteria, 
micrococci, and similar low forms of life abound in and 
about the epithelial scales. 

Fungus of Tinea Circinata { Trie Jiophy ton Tonsurans). 
Conidia. — In proportion to mycelium, and compared 



TINEA IMBRICATA. 171 

to tinea imhricata^ very few indeed, many scrapings 
having to be searched before they are found. In size 
they are much the same as those of tinea imhricata^ 
but are more globular in form, and are often com- 
pressed in the direction of the axis of the short 
chain in which they are generally arranged. The 
terminal conidium is large and bulbous and more 
oval. They are generally seen to be connected with 
mycelium. 

Mycelium varies in breadth, as does that of tinea 
imbricata, but it is distinguishable from the latter 
by numerous swellings and constrictions and other 
irregularities in outline. This contrast is very notice- 
able. It is frequently articulated to form conidia, 
and septa and branches are common. Generally the 
threads contain very minute dark granules. The 
course of a mycelial thread of tinea imbricata is usually 
long, straight, or gently curved ; that of the mycelia 
of tinea circinata is generally short, ii-regular, and 
much convoluted. 

Stroma^ I have not detected with certainty. 

Experiments in Inoculation. 

The contrast in the clinical features of these two 
diseases, and the microscopic characters of their fungi, 
is decided. If I now show, by careful observation of 
the results of their successful inoculation, that these 
distinctive features are transmitted and maintained 
in every instance and in the same individual, the 
assumption of Dr. Tilbury Fox and others, that the 
disparity in the appearance of the varieties of ring- 
worm is produced by differences in climate and other 
circumstances, will not hold. 



172 TINEA IMBRICATA. 

Inoculation of Tinea Circinata. 

I inoculated two assistants by scratching the 
ejDidermis on anterior surface of forearm, and rubbing 
into the spot scrapings from the ring of Tchok, 
Case 2. The inoculated spot was protected by a 
pledget of cotton wool held in place by strapping. 
The following are my notes, made every few days 
during the j^i'ogi'ess of the inoculation : — 

5th day. — Dressings removed. One case has completely 
failed ; but on the forearm of the other, close to, but not quite 
over, the seat of inoculation, is a very minute vesicle. 

8th day. — A red, itching spot, slightly, if at all, elevated, 
about tV'iii- ill diameter, where the vesicle was. 

10th day. — Yesterday, the original inoculation spot became 
itchy and red, and to-day is larger and more itchy. The 
other spot, where the vesicle was, has not extended, 

] 5th day. — The site of the inoculation is now occupied 
by a circular patch, x^-in. in diameter. It is red, rough, 
slightly elevated, and itchy, and is beginning to assume the 
appearance of a ring, the centre being paler than the circum- 
ference and distinctly depressed. The site of the vesicle is 
now included by the ring. 

17th day. — The ring, gradually enlarging, is now over 
-f--in. in diameter, perfectly circular, abrupt towards sound 
skin, shading off towards centre, elevated, very itchy, with 
one or two minute vesicles on it. Trichophyton easily found 
in scrapings. 

19th day. — Ring is now | -in. in diameter, ^-in. in breadth, 
with a bright red, slightly furfm-aceous surface; no large 
scales. 

22nd day. — Ring is now xf-in. in diameter, rather more 
scurfy and less elevated ; the minute fm-furaceous scales 
are attached at the outer border of the ring; loose on the 
inner. 

24th day. — Ring nearly If -in. Skin in the centre appears 
to be quite healthy. 



TINEA IMBRICATA. 173 

26tli day. — Diameter about one inch. Outline more 
irregular. 

28tli day. — Ring is now oblong, irregular, and faded- 
looking ; greatest diameter measures l-^-in. 

33rd day. — Hing measures l-^^-in., but is now not com- 
plete, being interrupted in several places. Outline also is 
more or less irregular in shape and colour. In places there 
are bright red spots, in other places paler spots ; and some of 
these are in advance of the general body of the disease. 
Centre is quite healthy. The disease was to-day destroyed by 
the application of iodine liniment. 

During the progress of the inoculation,the fungus was looked 
for from time to time, and always found. Its characters were 
those of trichophyton tonsiu-ans, already described, and 
corresponded, as did all the other features of the inoculated 
disease, with those of the ringworm from which it was 
derived. 

Inoculation of Tinea Imhricata. 

I was anxious to make a successful inoculation of 
tinea imhricata in the same individual, and accord- 
ingly, as soon as I was convinced that the inoculation 
of tinea circinata had healed, I inoculated his other 
arm with scales from a case of tinea imhricata. These 
scales were quite two months old, having been kept 
in a stoppered bottle all the time. There was no 
result. I then sent for the man Liam, Case 1, and, 
with fresh scales procured from him inoculated the 
left forearm iu two places, front and back, treating 
the spots in exactly the same manner as I had done 
when on the same man I inoculated tinea circinata. 

6th day. — Dressings removed. At the seat of inoculation 
the epidermis has been shed, leaving a very fair ring of 
undermined epithelium surrounding the spot, which is about 
-|--in. in diameter; it is not elevated or altered in colour, 
though rather more glossy than the surrounding skin. 



174 TINEA IMBRICATA. 

Fungus was searclied for, but was not found. The shedding 
of the epidermis I look upon as the result of the irritation, and 
in no way the consequence of the fungus. 

8th day. — Appearance much the same as two days ago, 
though, possibly, more distinct. No trace of fungus in scales, 
and no itching. 

10th day. — The circle of desquamating delicate epithelium 
has disappeared, but noAV there is a minute brownish spot on 
each seat of inoculation, that on the back of the arm being 
double. These spots are about i^-in. in diameter, and do not 
itch. 

12th day. — The brown spot on the anterior surface of the 
arm is slightly larger ; it is not at all inflamed or very 
distinctly elevated, and does not itch. The epidermis covering 
it is very delicate, and a considerable flake of this is easily 
peeled off by piercing it, and running a needle between it and 
the corium. Transferred to the microscope, this is found to 
be crowded with mycelium and innumerable chains of conidia 
of the same character as found in the case of tinea imhricata 
already described; the mycelium is perhaps more plentiful 
and made up of shorter lengths, and in many of the threads 
are large quantities of brown pigment-granules arranged as 
nuclei. The spot on the back of the arm he has scratched ; 
it is red, denuded of epithelium, and crusted in consequence. 

13th day. — The spot in front is now \-va.. in diameter, of 
a brownish colour, hardly elevated, and is surrounded by a 
delicate overhanging fringe of detaching epidermis. That 
on back of arm still damaged by the scratching ; one half is 
occupied by a small crust, the other half resembles the spot 
on the front of the arm. It is red and swollen, 

17th day. — The spot has now assumed a distinctly ringed 
appearance, and^measures f-in. in diameter. He says it itches 
more than does the tinea circinata on the other arm, and has 
in consequence been scratched and rather sj^oiled. In tinea 
circinata, the surface of the ring is convex ; in this it is ridged 
like the crest of a breaking wave. I believe this degree of 
elevation is, partly at least, attributable to the scratching. If 
carefully analysed, the spot is found to be made up of a series 
of concentric rings. From without, inwards, they are — 1, a 



TINEA IMBRICATA. 175 

brownish-red ring, about -V-in- in breadth, lying apparently 
under the epidermis ; 2, the red elevated ring, from the ridge 
of which a complete circle of delicate, detached epithelium 
springs, its free edge looking inwards ; 3, a pale ring, with 
a glossy surface, surrounding 4, a central brown slightly 
raised spot, about |-in. in diameter. Ring on the back of the 
arm is not so distinct, and is not elevated. No redne ss or 
thickening of the skin ; but there is a shght deepening of 
colom' at the outer margin, a distinct ring of delicate scales, 
a paler circle, and a darker spot inside, just as on the front 
of the arm ; diameter of spot f -in. Fungus in both 
plentiful. 

18th day. — The spot in front is slightly larger, and a 
second ring of undermined and scaling epidermis is forming 
in the centre of the first ; this second ring is -nr-in. in diameter. 
The brown central spot visible yesterday has disappeared, and 
the sm'face it occupied is now paler than normal. The patch 
on the back of the arm is also larger, but as yet there is no 
second ring forming, the central bro%vn spot being still very 
distinct. 

19th day. — Spot on anterior surface : Outer ring over 
J-in. in diameter, inner ring -|-in. Spot on posterior surface : 
-i%-in. in diameter, without a central second ring, but the 
included space is frayed, and looks as if it had been well 
scratched. He says the itching is now much less troublesome. 

24th day. — Ring in front nearly f -in. in diameter. A 
third ring is now forming. On the back of the arm the 
eruption is more irregular. A third spot on the same arm, 
the result of another and later inoculation, is proceeding 
typically. 

27th day. — The patch in front is now -i%-in. in diameter, and 
a third ring has formed. 

29th day. — A fourth ring has formed on both spots. No 
thickening or signs of inflammation. Scales are kept small 
by frequent washings. Ring in front nearly an inch in 
diameter. 

31st day. — Four rings distinct and perfect. 

3Gth day, — Five rings. There is now considerable irrita- 
tion, especially about the outer rings, and a tendency to 



176 TINEA IMBRICATA. 

inflame and vesiculate ; the circles are in consequence not so 
perfect. Grreatest diameter nearly l|-in. 

41st day. — The weather has become very hot, and j)robably 
in consequence, the irritation in the spots has increased. The 
inner rings have been spoiled by scratching, but the two outer 
rings are quite distinct, though slightly inflamed. Diameter, 
If-in. The spot on front of arm protected by a cover, the other 
spots destroyed with iodine liniment. 

Several days afterwards, when the covering was removed, 
the patch was found much inflamed ; the rings could be traced, 
but the fungus apparently had died, as the disease made no 
further progress. The roughness and scaliness of the epi- 
dermis gradually subsided, and the part became natural in 
texture, though from the slight alteration in the colouring of 
the skin, the site of the rings could be traced for weeks 
afterwards. 

These experiments were repeated in two other cases with 
similar results. 

From this description of a successful inoculation, 
the nature and distinctive characters of tinea imhricata 
can easily be made out. After inoculation, as in tinea 
circinata^ there is an incubation period of about nine 
days. At the end of this time the fungus has multi- 
plied sufficiently to slightly elevate the epidermis 
under which it is growing, and form a brown mass 
between it and the corium. When this has attained 
a diameter of about f-iu., the epidermis in the 
centre gives way ; but, as it is still organically con- 
tinuous with the sound skin at its margin, it is not 
completely shed but remains a fringe round the 
central hole. By friction or other means, the free 
edge of the scale is from time to time removed ; and 
the brown central fungus and the tissues it is mixed 
with, now no longer protected by a closely adhering 
epidermis, are rubbed of£ as far as the attachment of 



TINEA IMBRICATA. 177 

the scale, and the exposed corium appears pale. Just 
beyond this point the advancing fungus shows 
through the epidermis as a brown rim, perhaps 
very slightly elevated, about TB"-in. in breadth. 
When the entire ring thus formed has attained a 
diameter of about J-in., a brown patch is again 
seen to be forming at its centre; this in its turn 
also cracks the young epidermis over it, and a second 
ring is formed inside the first, which it follows in its 
extension. A third brown central patch is formed in 
the centre of the second circle, and behaves in exactly 
the same manner ; and so on with a fourth, fifth, and 
never-ending series of concentric rings. 

There is a marked contrast between tinea circinata and 
tinea imbricata in the parts and extent of the sMn they 
respectively attack. The former elects, in preference 
to any other locality, those parts of the body which 
are usually covered with hair, as the scalp, axilla, 
and pubes ; the latter, on the contrary, avoids these 
situations. The Chinese have very seldom a strong 
crop of hair on the front of the chest, on the small 
of the back, or legs and arms ; yet these situations, 
so frequently covered with hair in the European, 
are, strange to say, shunned by the fungus of tinea 
imbricata. If, however, tinea imbricata has spread 
on to a hairy part, the hair follicles are not invaded 
by the fungus, as in tinea circinata,^ and the hair 
continues firmly implanted, glossy, and natural. 

Again tinea imbricata.^ if it has been in existence 
any length of time, involves a very large surface, as 
an entire limb, or side of the trunk, or oftener still, if 
not checked, nearly the whole surface of the body. 
Tinea circinata., though sometimes including in its 

N 



178 TINEA IMBRICATA. 

rings large areas^ yet, by its nature is hindered from 
attacking at one time the entire skin, as an interval 
must elajDse before a second ring can follow the first. 
In point of fact, in tinea circinata, though there may 
be several rings in existence at one time, and some of 
them include a very large area, yet we seldom have 
to deal with surfaces more than six inches in diameter, 
usually with much smaller. 

The disease advances over the skin at about the rate 
of a quarter of an inch weekly ; this is about the rate 
of progress in tinea circinata also. As advancing rings 
spread, their regularity is modified by the shape of the 
parts, the nature of the skin they travel over, and by 
encountering other systems of rings. Thus, after a 
time, the plan is lost or obscured, while the pattern of 
the disease, so to speak, is everywhere preserved. 

In fair-skinned races, chloasma, or pityriasis versi- 
color, shows as a brown or fawn-coloured patch on 
a light ground. In the dark-skinned races, on the 
contrary, it shows as a lighter coloured, patch on a 
dark ground. In the yellow- skinned races, like the 
Chinese, in some the colour of the patch of disease 
and general complexion so nearly correspond that it 
is only by observing the scaliness and slight elevation 
of the part, and by the use of the microscope, that 
we can pronounce it chloasma. In coolies, and those 
whose skin is darkened by exposure to the weather, 
the spot is always much paler than the healthy skin ; 
in the pale, sallow-faced shop-keeper, always darker 
than the healthy skin. A very large proportion of 
the natives of this district can show patches of 
chloasma, usually about the neck, chest, or shoulders, 
or over the abdomen just under the waist-belt. Every 



TINEA IMBEICATA. 179 

one is familiar with, the mottled appearance the skin of 
coolies frequently presents. I have satisfied myself 
that this is chloasma, and is entirely owing to the 
microsporon furfur, which can be found in great abun- 
dance in any of these cases. The fungus I have 
contrasted with that from cases of chloasma brought 
from Europe and America, and • find them to be 
identical. It is situated on the under surface of the 
outermost pellicle of epidermis, and the spherical, 
double-outlined conidia, arranged in clusters, and 
short much- jointed mycelium are quite characteristic. 
The colour of the chloasma spot is owing to the colour 
of the fungus, and not of the skin; and being the 
same or nearly the same in every case, it appears 
lighter than the skin in dark races, and darker than 
the skin in fair races. 

Limited Geographical Area within which Tinea Imhricata 
Flourishes. 

An additional argument for separating this disease 
from tinea circinata and placing it as a species by 
itself, is supplied by the peculiarity of its geographical 
distribution. I have seen a great many cases in Amoy, 
but, with one exception, all of these have been at 
one time in the Straits of Malacca, or islands of the 
Malay Archipelago, and it was there the disease was 
acquired. I have seen cases in South Formosa also, 
but as I made no inquiries as to where their skin- 
affection was acquired, I cannot say whether it was 
indigenous or imported. For a considerable part of 
the year the climate of South Formosa is very like 
that of the Straits. The instance I refer to as having 
arisen in Amoy was in the person of the relative of 

N 2 



180 TINEA IMBRICATA. 

a man who had returned from the Straits covered 
with the disease. Disregarding this case, it would 
a^Dpear that some peculiarity of climate is necessary 
for the ready spread of the disease from person to 
person, although when once established in the 
individual it flourishes in China as well as in its 
home, as proven by the results of inoculation. 
Possibly, in the warm, moist, equable climate of 
the Straits, there is developed some fungus element 
which will not grow in the colder, drier climate of 
China, and the spontaneous spread of the disease is 
effected by this. 

I believe that tinea imhricata is the disease de- 
scribed as " Pita," or " Tokelau itch," in the " Scheme 
for obtaining a Better Knowledge of the Endemic Skin 
Diseases of India," edited by Drs. Fox and Farquhar, 
and also alluded to by Dr. Thin in a late "Practitioner." 
If it is identical with the Samoan disease, we know 
that it spreads rapidly enough under suitable cir- 
cumstances. As far as I am aware, there is no other 
epiphytic skin disease, with the doubtful exception 
of the fungus foot of India, with so limited a geo- 
graphical distribution. 

Tinea Imhricata the Connecting LinJc between Chloasma 
and Tinea Circinata. 

Assuming that I have proved the existence of a 
parasitic skin disease affecting the rete Malpighii, we 
have now, apart from those confined, or nearly so, to 
the hairy scalp, three well-marked epiphytic skin 
diseases, viz. ; — tinea circinata^ tinea imhricata^ and 
chloasma^ each affecting a different layer or element 
of the skin. Tinea circinata has its seat in or 



TINEA IMBRICATA. 181 

on tHe corium, or deep layer ; tinea imhricata in 
the rete Malpighii^ or middle layer; and chloasma 
in the epidermis or surface ; and to this selection of 
locality, rather than to any peculiarity in the habits 
of their respective fungi, seems to be due the 
characteristic clinical features of these different 
diseases. The epidermis, so abundantly and con- 
stantly reproduced, supplies a never-failing sujDply of 
pabulum for its fungus ; so that, while spreading at 
the margin of the patch, there is no death of fungus 
or subsidence of the disease in the centre of the part 
affected, the disease relinquishing no place once 
attacked. Hence its appearance in a circular patch, 
uniform in colour and texture throughout its extent. 
In tinea circinata, on the contrary, the fungus, living 
on some element of the more slowly reproduced corium, 
while spreading towards hitherto unexhausted, un- 
affected tissue, is compelled to relinquish what it has 
already passed over, dying for want of the suitable 
element ; hence it assumes the form of a single ring. 
Tinea imhricata is the link, both in position and 
appearance, between these two, as the rete Malpighii 
occupies a place intermediate in position and facility 
of production between corium and epidermis. The 
pigment layer is not so easily or rapidly formed as is 
the epidermis ; hence the fungus cannot be universally 
distributed as a patch over the affected part ; but the 
tissue being more easily and quickly reformed than 
the corium, the fungus element has the opportunity of 
starting afresh before from lapse of time or want of 
food it has completely died out ; thus its successive 
generations advance in succeeding rings. 

I am aware that many dermatologists favour the 



182 tinea" IMBRICATA. 

view that the various skin fungi are but modifications 
of either penicillum or aspergillus, and of each other, 
and that the same fungus will give rise to favus, 
chloasma, or tinea circinata according to circumstances. 
I cannot agree with this opinion. If it is correct, how 
comes it that in the same man I can by inoculation, 
as often as I wish, produce on one arm tinea circinata 
from a case of tinea circinata, and at the same time, 
on the other arm, tinea imlricata by inoculating from 
tinea imhricata ; but never tinea circinata from tinea 
imbricata, or vice versa ? The diseases, at any rate, 
whatever may be the nature of their exciting fungi, 
possess the most essential quality of distinct species — 
they breed true. 



INDEX. 



— T^^^^Afi'^— 



Abscess caused by death of parent 
filaria, 127 

Adams, Dr., on filarial periodicity, 50 

Age, influence in determining presence 
of filaria, 74 

Amoy, filaria sanguinis hominis at, 72 

Ardraseer, Dr. Jamsetjee, on lympli- 
scrotum, 86 

Atmospheric pressui-e, efltect on filarial 
periodicity, 52 

Baelzj Prof., on distoma Eingeri, 
139 

Bahia, filaria sanguinis hominis at, 73 

Bancroft, Dr., discovery of mature 
filaria by, 4 

Carter, Dr. Vandyke, on IjTnph- 
scrotum, 87 

and chyluria, 95 

Case of tinea oircinata, 167 
tinea imbricata, 164 

Case I. FUarise in the blood ; enlarged 
spleen ; ansemia ; experiment 
on inversion of filarial period- 
icity, 54 

Case II. Experiment on filarial period- 
icity, 58 

Case III. Experiment on filarial 
periodicity, 59 

Case IV. Chyluria ; filariee in the blood 
and urine ; an attempt to 
ascertain whether filarial 
periodicity be dependent on 
quotidian and intermitting 
reproduction, or whether it 
be altogether independent of 
the act of parturition, 65 



Case V. Lymph-scrotum ; filaria em- 
bryos in the blood and lymph, 
91 

Case VI. Lymph -scrotum ; removal 
under chloroform ; periodicity 
of filaria embryos not affected 
by chlorofoi-m, 94 

Case VII. Excessive development of 
lymph- scrotum and varicose 
inguinal glands ; filarige in 
scrotal lymph (Plate IV.), 
94 

Case VIII. History of elephantoid 
fever; chyluria and lymph- 
scrotum co-existing ; elephan- 
tiasis of the scrotum, 97 

Case IX. Elephantoid fever ; lymph- 
scrotum and intermitting 
chyluria, 98 

Case X. Hsematozoa ; chyluria and 
lymph-scrotum, 99 

Case XL Haematozoa ; chyluria and 
lymph -scrotum, 100 

Case XII. Hsematozoa ; elephantiasis 
and lymph -scrotum combined, 
102 

Case XIII. Haematozoa ; lymph- 
scrotum and elephantiasis 
scroti, 102 

Case XIV. Elepha-ntiasis of the scro- 
tum and lymph-scrotum com- 
bined ; filaria embryos in 
lymph from varicose groin - 
glands, but not in the blood, 
103 



184 



INDEX. 



Case XV. Lymph-scrotum passing 
into elephantiasis ; hsema- 
tozoa in blood and lymph 
from scrotum ; amputation, 
104 
Case XVI. Lympho-elephantoid scro- 
tum ; filarise in lymph from 
scrotum and in the blood, 
106 
Case XVII. Lymph -scrotum follow- 
ing operation for elephan- 
tiasis scroti, 107 
Case XVIII. Lymph-scrotum and 
elephantiasis of the scrotum 
combined; filarise in lymph 
and blood; operation; ele- 
phantiasis of the leg deve- 
loped (Plate v.), 109 
Case XIX. Elephantiasis of the leg ; 
lymph - scrotum ; varicose 
groin - glands ; filarise in 
lymph from groin -glands and 
scrotum, and also in the 
blood (Plate VI.), 113 
Case XX. Lymph- scrotum ; varicose 
groin - glands ; elephantoid 
condition of the skin of the 
left thigh ; filarise in lymph 
from glands, but none in the 
blood, 115 
Case XXI. Elephantiasis of the 
leg ; varicose groin- glands ; 
lymphous discharge from 
leg ; filarise in groin-glands, 
but none in the blood ; sub- 
sequent development of chy- 
luria (Plate VII.), 116 
Case XXII. Lymph-scrotum ; filaria 
embryos in lymph from scro- 
tum, but not in the blood ; 
excision of part of the scro- 
tum ; parent filaria in dilated 
lymphatic, 123 
Case XXIII. Abscess in the thigh, 
caused by the death of the 
parent filaria ; varicose groin - 
glands ; fragments of the 
mature wonn in the contents 
of abscess, 127 



Case XXIV. Filarise in blood ; en- 
larged, indiurated, and partly 
varicose groin-glands ; ele- 
phanto-oedematous legs ; ova 
of filaria in lymph from 
groin-glands, 130 
Case XXV. Lymph-scrotum ; filarise 
in lymph from scrotum, also 
ova containing coiled-up and 
active embryos ; small num- 
ber of parasites in the blood ; 
operation, 131 
Case XXVI. Distoma Ringeri; hsemo- 

ptysis, 136 
Case XXVII. Distoma Eingeri ; 

hsemoptysis, 143 
Case XXVIII. Distoma Eingeri ; 

hsemoptysis, 144 
Case XXIX. Lymph-scrotum and ele- 
phantiasis scroti combined ; 
profuse discharge of lymph ; 
gTeat debility ; fidarite in 
blood and lymph ; operation ; 
death ; post-mortem exami- 
nation ; ligula Mansoni in 
abdomen, 159 
Chloasma, appearance of spots on 
different coloured skins, 178 
habitat of fungus of, 181 
Chloroform narcosis, effect on filarial 

periodicity, 94, 105 
Chorional envelope, stretching of, by 

embryo filaria, 24 
Chylui-ia, 20 

and filaria sanguinis hominis, 89 
and lymph-scrotum, Carter on, 95 

Lewis on, 96 
and varicose lymphatics, Eoberts 

on, 97 
with elephantiasis of the leg, il6 
Cobbold on distoma Eingeri, 138, 154 

Ligula Mansoni, 157 
Destiny of embryo filaria, 62 

Dr. Myers on, 62 
Diagnosis of endemic hsemoptysis, 142 
Distoma Eingeri, Cobbold on, 138, 154 
embryo of, 148 

geographical distribution of, 141 
intermediary host of, 153 
mature form of, 137 



INDEX. 



185 



Distoma Ringeri, ova of, 135, 144 
position in the lungs, 154 
prevalence in Formosa, 141 

Japan, 139 
Prof. Baelz on, 139 
Druitt, Dr., on lymph-scrotum, 88 
Elephantiasis and lymph -scrotum co- 
existing, 101, 113 
lymph-scrotum supervening on, 

108 
of leg following excision of lymph- 
scrotum, 109 
Orientalis, Dr. Allan Webb on, 101 
•with chyluria, 116 
Elephantoid disease, parasitic nature 

of, 82 
Elephantoid fever, 85 

influence of lunar cycle on, 86 
Embolism of lymphatics by ova of the 

filaria, 26, 122 
Embryo filaria, description of, 6 

destiny of, 62 
Endemic haemoptysis, 134 
diagnosis of, 142 
in Formosa, 141 
in Japan, 139 
treatment of, 154 
Fayrer, Sir J., on lymph-scrotum, 88 
Female filaria, 4, 125 
Fever, effect of, on filarial period- 
icity, 60 
Filaria Bancrofti, 4 
corvi torquati, 18 
immitis, 18, 40 
picse mediae, 18 
sanguinis hominis, 1 

abscess caused by death of 

parent, 127 
and chyluria, 89 
associated morbid conditions, 

20, 77 
female, 4 

in Amoy, China, 72 
ia Bahia, Brazil, 73 
influence of age, 74 
sex, 75 

occupation, 75 
intermediary host, 10 
male, 4 
statistics of, 71 



Filaria sanguinolenta, 45 
Filarial periodicity, 8, 32 

Dr. Mortimer G-ranville on, 57 
Dr. Stephen Mackenzie on, 50 

inversion of by, 54 
effect of atmospheric pressui-e on, 
52 
chloroform, 94, 105 
eating on, 59 
fever on, 60 

interrupted sleep on, 60 
light on, 53 
sleep on, 54 
temperature on, 52 
waking on, 59 
Fox, Dr. Tilbury, on ringworms, 163 
Fungus of tiaea circinata, 170 

tinea imbricata, 169 
Gralactocele , 12, 30 

Greographical distribution of tinea 
imbricata, 179 
distoma Ringeri, 141 
G-roin-glands, varicose, 83 

tapping of, 84 
Habitat of filaria, 5 
Hsemato-chyliiria or hsematuria, 21 
Haemoptysis, endemic, 134 
Intermediary host of filaria sanguinis 
hominis, the mosquitos, 10 
distoma Ringeri, 153 
Lewis, Dr. T., discovery of filaria 
embryo in blood by, 4 
mature filaria by, 4 
on stretching of chorion by filaria 

embryo, 24 
on lymph-scrotum, 88 
and chyluria, 96 
Light, effect of, on filarial period- 
icity, 53 
Ligula Mansoni, 157 
Cobbold on, 157 
structure of, 158 
Lymph, ova of filaria in, 129 
Lymph-scrotum, 20, 82 

and filaria sanguinis hominis, 91 

Dr. Ardraseer Jamsetjee on, 86 

Dr. Druitt on, 88 

Dr. T. Lewis on, 88 

Dr. Vandyke Carter on, 87 



186 



INDEX. 



Lymph-scrotmn, Dr, "Wong Fun on, 87 
Rindfleisch on, 88 
Sir J. Eayrer on, 88 
Sir J. Paget on, 88 
Surgeon K. McLeod on, 88 
Lymphatics, the habitat of the 

filaria, 5 
Lymphocele, 12 

Mackenzie, Dr. Stephen, on filarial 
periodicity, 50 
on inversion of periodicity, 54 
Malay Archipelago, tinea imbricata in 

the, 179 
Male filaria, 4 

McLeod, Surgeon K., on lymph- 
scrotum, 88 
Metamorphosis of the filaria in the 

mosquito, 12 
Mortimer Granville, Dr., on filarial 

periodicity, 57 
Mosquito, the intermediary host of 
filaria sanguinis hominis, 10 
Myers, Dr., on filarial periodicity, 50 
on the destiny of the embryo 
filaria, 62 
Occupation, influence of, in deter- 
mining presence of filaria, 75 
Ova, embolism of lymphatics by, 

26, 122 
Ova of filaria in lymph, 129 
distoma Ringeri, 135, 144 
development of, 146 
Paget, Sir J., on lymph-scrotum, 88 
Parasitic nature of elephantoid dis- 
eases, 82 
Parent filaria, 4, 125 

abscess caused by death of, 127 
Parturition of the filaria a continuous 
process, 69 



Periodicity, filarial, 8, 32 
Rennie, Dr., on filarial periodicity, 50 
Rindfleisch on lymph- scrotum, 88 
Ringer, Dr., discoverer of mature 

distoma Riugeri, 135 
Roberts on chyluria and varicose 

lymphatics, 97 
Sex, influence of, in determining 

presence of the filaria, 75 
Sleep, effect of, on filarial periodicity, 
54, 60 
Dr. S. Mackenzie on, 54 
Statistics of filaria sangixinis hominis, 

71 
Temperature, effect of, on filarial 

periodicity, 52 
Tinea circinata, case of, 167 
fungus of, 170 
habitat of fungus of, 181 
inoculation of, 172 
Tinea imbricata, 162 
case of, 164 
fungus of, 169 

habitat of fungus of, 177, 181 
inoculation of, 173 
Treatment of filaria disease, rationale 
of, 70 
endemic haemoptysis, 154 
Varicose groin-glands, 20 
lymphatics, 83 
tapping of, 84 
Waking state, effect of, on filarial 

periodicity, 59 
Webb, Dr. Allan, on elephantiasis 

Orientalis, 101 
Wong Fun, Dr., on lymph -scrotum, 

87 
Wucherer, discovery of the embryo 
filaria by, 4 



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